REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL APPLICATION (A Privileged Communication) ARIZONA REGIONAL MEDICAL PROGRAM RM 00055 5/71 University of Arizona College of Medicine April 1971 Review Committee Tucson, Arizona 85721 Program Coordinator: Dermont W. Melick, MD, Requested: Direct Costs 02_ (6 mo, ) 93 94 05 (6 mo.) TOTAL Core $156,650 -0- — #0- -0- $ 156,650 gi (serv. Areas) “ 37,475 $157,932 $209,191 $108,684 513,282 CE(Phys.) #14 72,798 147,010 176,946 92,744 489,498 Ariz. ECHO #15 193,762 . 324,094 204,064 . 69,081 791,001 Cont. Ed. Nursing #16 31,034 52,135 55,373. 25,789 164,23) TOTAL $491,719 $681,171 $645,574 $296,298 $2,114,762 Current Funding: A funding history summary is appended, The current 2nd year is funded at $811,191 d.c.o. for core and five projects. The commitment for the third*year is for $304,081 d.c.o. for the continuation for five projects only. The Region is to submit a triennium application August 1971 and the core budget is estimated d.c.o.: 03 - $994,586; 04 - $1,067,242; and 05 - $1,123,561 (total - $3,185,389). Geography-Demography: The ARMP serves the entire state of Arizona, a jand area of 114,000 square miles and a population of 1,741,000. The state is bordered by California and Nevada to the west, Utah to the north, New Mexico to the east and Mexico to the south. Medical facilities: 1) University of Arizona Medical School will graduate its first class in 1971: 2) seven schools of nursing, two of which are baccalaureate degree programs; 3) five schools of medical technology; and 4) six x-ray technology facilities. Medical manpower includes 2,120 physicians (132 per 100,000 population); 241 osteopaths, and 5,000 nurses (348/106,000). _ Arizona &MP . -2- RM 00055 (5/71 Background: The ARMP began in Spring 1966 when the Governor appointed a ee steering committee headed by the Dean of the Medical School. - The initial grant application was submitted December 1966 and support for : planning was authorized for two years and three months beginning April 1, 1967. The Dean of the Medical School served as part-time program coordinator until September 1967 when the current coordinator was employed on a full- \ time basis. Due to delays in the review and funding of the Region's operational program, the planning period was extended by nine months to a total of three years. Planning awards d.c,o.: Ol - $119,045; 02 - $409,108; 03 - $375,209; Total - $903,362. In June 1968, the Region submitted an operational. grant application for support of a pulmonary disease project. Based on the findings of the August 1968 site visit, the November 1968 Council recommended that the application be returned for revision. In May 1969 Council considered the initial operational application. As recommended by Council, a site visit was made that same month to 488e85 | the Region's operational capability. The application requested support for core staff activities and six projects. The site visit team was greatly concerned about the dominating needs of RMP in Phoenix and peripheral areas, and the contrast in the Region's plans to concentrate its headquarters near the Medical School in Tucson. Regional problems noted included: 1) need for better health care for the minority groups (126,900 Indians - 8% of the population and 187,000 Mexican-Americans - 11% pop.); 2) the State Medical Association's apparent disinterest in RMP; 3) the medical school had only recently begun and could not assure immediate strong support; and 4) 75% of medical service activities were in Maricopa County (Phoenix). Of 1,650 physicians in the State, 55% are in the Phoenix area and 30% in Tucson. Osteopaths are the primary health care providers in a number of counties. Sixty vercent of the hospitals in Arizona have less than fifty beds. There waa some concern about’. the bylaws that provided the Dean of the Medical school with the authority to appoint the Regional Advisory Group. The site visitors vointed out that the bylaws were not explicit regarding the Regional Advisory Group responsibility in appointment of its members and approving. applications. It was also’ believed that the evaluation capability of the Region should be strengthened by acquiring the services of a specialist. Impressions of staff leadership were favorable. Although there were some major problems, the team believed there was adequate evidence that the ARMP was ready to assume operational status. The visitors were convinced that further planning would not add to their capacity for implementing an operational program. Following approval by the August 1969 Council, $821,521 (d.c.o.) was awarded ‘the first year for Core and five projects. During the first year, Council recommended non-approval action II for four proposals; Nutrition Care, Education in Coronary Care, Community Education for Nurses, and Long-term “Education for Nursés. In light of Counctt*s disaporovat ofthe tatter three and their suggestions, the Region redeveloned a program for coronary care training which wil] ultimately involve five projects. Two of these, #ly - Continuing Education for Nurses and #12 - Postgraduate Courses and Seminars for Physicians. Hospital! Personne! and Trustees were apnroved by the July 1979 Council. Fut not yet funded. Arizona RMP -3~ re The second year continuation application for $842,125 d.c.o. for core and five projects was reviewed by RMPS staff in December 1970 and upon their recommendation, $811,191 d.c.o, was awarded. The broad goals were essentially the same as originally stated, but the 102 (1971) objectives were diffuse. Staff expressed hope that the objectives (long and short-term, data-based, and priority-oriented) will be better presented in AR trienniunm application submission to RMPS August 1971. Staff also expressed concern that the half million dollar core is directing most of its energies into development of projects for which there will be insufficient RMPS support. It was believed that there would be wisdom in the Region's reassessment of its operations in relation to priority needs and current available resources. In light of federal funding restraints some core activities might be appropriately redirected. A copy of staff comments and recommendations to the Acting Director, RMPS is appended. Goals Objectives and Priorities as described in the recent second year continuation application: The goals and objectives are essentially the same as previously stated, but have been restructured with more detail and time frames for management monitoring. Goals in terms of core staff and projects are 4& follows: I. Develop Adequate Health Manpower Resources. A) Update the knowledge of Health Professionals B) Increase the number of Health Professiotials C) Innovative use of manpower D) Increase the opportunity for upward mobility of Health Personnel II. Improve Community Health Programs. III. Develop Cooperative Relationships Among Health-Related Organizations in Arizona. IV. Have the Necessary Financial Organization Support to Accomplish the ARMP Objectives. The 102 objectives are related to the following critical heaith igsues: 1. Gap between new biomedical knowledge and its application to patients; 2. Availability and accessibility of health service; 2. Health needs of the poor, children, migrant workers and Indians; 4&4 Inner-city health problems; 5. Shortage of health manpower. Arizona RMP he RM 00055 5/71 Priority ranking for the second year: Core first, Project #4 - Continuing Education for Nurses second, Project #3 - Chronic Pulmonary Disease third, Project #6 - Cardiopulmonary Resuscitation fourth, and Project #5 - Recruitment and Continuing Education Social Service last. Approved unfunded projects and those in the present application are not ranked. A five-year long-range plan is to be fully described in the triennium application due August 1971. Organization Structure and Processes: The organization of the ARMP remains essentially the same. The 17 RAG members are appointed by the Dean. The RAG elects its Chairman, Vice- Chairman and five man Executive Committee. The Chairman and Vice-Chairman serve the same offices on the Executive Committee. Changes in the bylaws as amended March 1970 expanded the RAG term from two to three years (may be reappointed for two additional terms) and include a provision allowing the RAG to delegate to the Executive Committee responsibility and final authority for final approval of applications. The Executive Committee also serves ag the Review Committee. Thirteen committees (7 categorical and 6 area or ad hoc) with 189 members are utilized by the Region. Relation- ships of the RAG with other health. groups includes the CHP 314-A Agency, Arizona Heart Association, Arizona Division of the American Cancer Society, and Indian Health Service. The RAG Chairman is President of the Arizona Medical Association. oe Arizona law requires thet all Regional Advisory Group members serve on the ‘Advisory Council of the Arizona Health Planning Authority 314-A. To | permit CHP flexibility in appointing the required 51% consumer representation to the Council, the RAG size and number of consumer members have been kept to a minimum. CHP has not been included in the ARMP review process. There seems to be evidence of tie-in with professional resources including 314-B Agencies. Subregion activities will be undertaken as necesgary, i.e., project #16 nursing education, Yndianm reservations, model cities, continuing education service areas, etc. The overall strategy, however, will be region-wide programs,- : Core: According to the 02 continuation application, much of the projected core activities revolve around the submission, approval and funding of several new projects. Projects being developed include home dialysis, multiphasic screening and rheumatic fever, categorical disease workshops, dial access, pediatric conferences, physician assistants and registeries. Planned core activities include educational programs for physicians and allied health professionals; efforts to train indigenous workers for model cities and neighborhood health centers; efforts for enactment of state legislation to legalize physician assistants; plan for state rubella vaccination program, assistance for further development of Area CHP in Arizona RMP -5- RM 0COS5 «65/71 the northern area, Phoenix and Tucson; continued studies for planning, including a survey of health manpower and continuation of "checklist" 20th century books. A notable objective is the cooperative arrangement with Maricopa county CHP Council to develop a proposal(s) for multiple funding of health programs for low income consumers comprised of many Mexican-Americans and Indians. An 01 year objective no longer alluded to: "explore the feasibility of having all health continuing education ‘.programs brought within the organized system of education in Arizona," Project Program Status: When reviewing the continuation application, staff was favorably impressed by project #4 - Continuing Education in Nursing Care of Patients an outstanding program with a record of success. This activity existed in a limited fashion prior to RMP support. The other projects, all education oriented, had been operational for only a few months and many were late tooling up. It was believed that a better assessment can be made at the time of the initial triennium review in the November 1971 cycle when more meaningful progress data should be available. Present Application: This is a,request for supplemental support for core staff for six months and support for four new projects for three years. Core Activities - The sum of $148,982 is requested for Requested additional core staff support to work Oniy 6 Months in the areas: 1) development of comprehensive health $156,650 services primary focus on prevention and early detection; 2) accelerated health manpower and facilities; 3) further integration of ARMP program activities with those of the CHP A and B agencies, Model Cities program, OEO and other public and private health-related program; and, 4) additional support and coordination of operational project activities, and increased responsibility delegated to the Region by RMPS. The supple- ment proposes adding 11 professional and 7 clerical positions, for a total staff of 58 (41 professionals and semi-professionals, and 17 clerical personnel). The request includes $7,668 for continuation of the pilot work on the dial access program which began in the previous year. A project proposal for this activity is planned as part of the triennium application submission to RMPS August 1971. , The proposed core supplement increases the current annual level to $816,600 d.c.o. Project #13 - A Broad Continuing Education Program Requested Ist Period For Physicians in Arizona - Development 6 Months of Continuing Education Service Areas. This is a $37,475 companion to Project #14 ~ Continuing Education for Physicians. Proposed by the University of Arizona College of Medicine, this is a project to organize 15 sub-regional continuing education areas to insure formal education opportunities to aij Arizona physicians, The areas will be organized through the coordination and assistance of the Arizona RMP -6- RM 00055 5/71 CESA Program Coordinating Committee for Medical Education. A project director and the Committee are to be appointed by the Dean of the Medical School. The focal point for each CESA will preferably be a hospital and each area will have a local functioning committee. Each CESA focal point is to have teaching facilities and.equipment, The local committees will be responsible for working with fellow physicians in the development of workshops and conferences to meet their needs. The Committee and four CESAs are. to be functionable within six months, ten CESAs within eighteen months and all fifteen within the third project period. The educational] activities will be provided through the resources of Arizona health organizations, i.e., the University Colleges of Medicine and Continuing Education; ARMP; and Arizona Medical Association. The project will be monitored and evaluated by project personnel with assistance from ARMP core staff, the CESA Committee and participating physicians. Evaluation procedures will include physician self-evaluation questionnaires, comparative patient management problem scores and comparative chart audits. The applicant assumes that the project will be supported by the Medical and Osteopath Associations, and fees after cessation of the grant. Second Period : Third Period Fourth Period (6 mos.) $157,932 -§209,191 $108, 684 Speke ® C2 Project #14 - A Broad Continuing Education Program Requested First Period for Physicians in Arizona Workshops, 6 months Conferences and Other Postgraduate Medical Education. $72,798 Proposed by the University of Arizona Medical School, this is a companion project to #13 CESA. The purpose of this project is to deliver the continuing education to physicians through the fifteen CESAs on a structured and regular basis. The proposed program is based on responses to a survey of physicians, Medical Association resolutions, and 18 workshops conducted in 1970 by ARMP. The project director will serve on the CESA Coordinating Committee and will work closely with that project as well as the each chairman of the 15 local committees. Designated disease categorical coordinators, all of the College of Medicine, will have responsibility of development of specific curricula in response to wishes of the local committees. The workshop conferences will be physician oriented, but allied health personne] will be welcome, and when appropriate they will be utilized as faculty. Topics of special value to practicing physician will be reproduced into slide cassette tapes and copies distributed to all of the CESAs. Selected cassettes produced by other health organizations will also be distributed. Workshop projections: 17 during the first six months, 40 in 1972, 53 in 1973 and 30 in first six months of 1974. Arizona RMP -7- RM 00055 5/71 Effectiveness of the workshops will be determined by project staff, ARMP staff, the CESA Coordinating Committee, local medical education committees and participating physicians. Information upon which evaluation will be based includes number of workshops, attendance, post workshop suggestions by attending physicians, periodic questionnaires to physicians attending and those not attending, and the extent CESAs develop programs bevond the workshops. An attempt will also be made to evaluate behavorial changes. , With repard to continuation after three years of ARMP support, the applicant anticivater that some financing can be assumed by the College of Medicine through appropriate legislation. Other means of future funding might include assessment of the recipients and their organizations. Second Period Third Period _ Fourth Period (6 mos.) $147,010 $176,946 $92,744 Project #15 - Arizona Evidence for Community Heal. th Organization Conjoint funding proposed O1_ (6 mos.) 02 93 04 (6 mos.) TOTAL RMP $193,762 $324,094 $204,064 $ 69,081 $ 791,001 State & Local Health Depts. -0- 81,024 _ 249,412 161,190 491, 626 Total Direct Costs $193, 762 $405,118 $453,476 $230,271 $1,282,627 Proposed by the Arizona Department of Health, the purpose of the project is to provide for a unified system for acquiring Arizona population health data. Similar to a system used in Michigan, a pilot test was accomplished in Tucson (Pima County) and Phoenix (Maricopa County). The project provides for a statewide expansion and includes: 1) collecting data about environ- mental and personal health conditions; 2) analysing the data and converting it into readily usable information for both technical and non-technical persons: 3) providing a mechanism for distribution of data at al] levels; and 4) provision for education to ensure use of data. - This system including 14 county health department sub-systems, will afford information necessary to planning development and evaluation to the State Health Department agencies including 314 (A), two CHP 314 (B) agencies, 14 county health departments, RMP and other health organizations. The Commigsioner of the Arizona Department of Health will appoint a project director and advisory committee, consisting of representatives of the Arizona RMP a8 RM 00055 5/71 participating organizations. Personnel already trained in the two pilot counties will be used to train personnel in the remaining twelve counties. The work projections are based on the Governor's designated six planning areas. Projections for implementations: Begin — Complete Area I & IT : F/L/T1 1/1/73 Area IIT 6/1/72 * 11/1/74 Area IV&V 7/1/71 1/1/74 Area VI 6/1/73 * 11/1/75 * Dates beyond the RMP funding relate to continuation of implementation through local support. Effectiveness of the project will be determined chiefly be frequency data ig drawn upon. Some random samples of the"person to person" acquired survey information will be ré-evaluated for accuracy. , The Arizona State Department of Health will request funding from the State legislature to begin mid 1973. Continuation of the project after cessation of RMP funding seems to rest with the legislative process. Most of the budget is for personnel. Of $122,002 for personnel the first six months, $73,011 is for positions (most already filled) for the Pima County and Maricopa Health Departments. $40,618 is budgeted for personnel in the State Health Department and $15,142 in the three county health departments of Gila, Yama and Pinal. Second Period Third Period Fourth Period (6mos.) $324,094 $204,064 $69,081 ” Requested First Period Project #16 - Continuation Education for Associate | ‘Six Months Degree and Diploma Nurses. Proposed by $31,034 the Northern Arizona University, the project aims to make available 30-40 hours of continued education to each registered nurse in Arizona by 1976. The project aims include the involvement of junior colleges in providing nursing continuing education opportunities in five non-metropolitan county areas with a focus on Indian Health Service nurses. Work projections: 1) annual 10-day workshops at the Northern Arizona ‘University for about 15 faculty members of associate and diploma nursing programs: 2) four annual workshops in non-metropolitan areas, utilizing resource faculty selected at the workshops for faculty; and 3) a 3-5 é¢ay course at the close of each project year for 25 of local workshop participants to specifically help them develop additional staff and leader- ship canabilities. Consultation services will also be offered to nurses in the target areas. Arizona RMP -9~ RM 00055 5/71 The section of the narrative dealing with the evolution of the project alludes -to two other nursing continuing education projects approved by ARMP, one of which is ongoing. However, specific relationships are not spelled out. Evaluation, will be based on the numbers of: 1) nurse participants; 2) nurses assigned positions of more responsibility as a result of the project education activities; and 3) particivating agencies and individual requests for consultation. Evaluation of effectiveness will include pre- and post-testing, assessment by faculty during consultation, course evaluations by participants, self-evaluations, post follow-up evaluations by employer and supervisors and nursing audits. The University of Arizona Department of Systems Engineering will be utilized in evaluation on 4 sub-contract arrangement. The applicant anticipates cost-sharing by cooperative arrangements, and even state legislative support, after cessation of the grant. Second Period Third Period Fourth Period (6 Mos.) $52,135 $55,373 $25,789 GRB/2/5/71 Date: Reply to Altn of: Subject: Arizona RMP #1 0- RM 00055 5/71 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE - PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION December 17, 1970 Staff Review December 11, 1970, of Arizona Regional Medical Program's second year continuation application, 5 GO3 RM 00055-02 - Acting Director Regional Medical Programs Service Chairman of the Month 6 - Pg ee i > ¢ Acting Chief, ,Regional Development Branch od x wrt S if . s ee Oba MOO _ Acting Chief,~Grants Review Branch 7 uv Request: This is a request for $842,125 d.c.o. which includes the com~ mitted level $811,191 and $30,934 carryover. Unexpended funds at the close of the current period are estimated at $30,957. Recommendation: Approval in the amount of the commitment $811,191 d.c.o. The recommendation includes advice to the Region about the concerns of the reviewers. Staff also believes that consultation and/or assistance at an early date may be helpful to ARMP prior to sub- mission of their initial anniversary review application. The use of carryover or new funds does not seem justified at this time. In some instarices, i.e., legislative backup assistance, utilization of existing core staff and/or rebudgeting would seem appropriate. Basis for the Level Recommended Requested Recommended " Commitment Carryover Total Core $503,300 1/ $30,184 $533,484 $503, 300 #2 Med, Lib. 36,211 -0- 36,211 36,211 #3. Pulm, Dis. 112,000 -0- 112,000 112,000 #4 Cont, Ed. Nursing Care 65,807 -0- 65,807 65,807 © #5 Recruit. & Cont’d Educ. Social Ser. 57,500 750 58,250 57,500 #1 CPR: 36,373 -Q- 36,373 36,373 ~ $811,191 $30,934 $842,125 $811,191 Arivona RMP -11- RM 00055 5/71 Harold Margulies, M.D. December 17, 1970 1/ $10,794 project evaluation 10,590 support of "dial-a-tape" pilot program until submission of the project to RMPS 2/1/71 (start 7/1/71) 8,800 health planner and writer (6 mos.) (cooperative effort with State Wealth Department, CilP A & B, and County Health Departments) backup for legislative approval of the Arizona Health Data Service $30,184 General Comments: The broad goals are essentially the same as previously stated, The 102 (1971) objectives enumerated and geared to completion dates are diffuse, Hopefully the objectives (long and short~ term, data based and priority oriented) will be better presented in the AR triennium application submission to RMPS August 1971. The organization is about the same. Arizona law requires that all ARMP RAG members serve on the Advisory Council of the Arizona Health Planning Authority (CHP 314-A). To permit CHP flexibility in appointing the required 51% consumer representation to the Council, the RAG size and number of consumers has been minimized, The RAG members are appointed by the Dean - a matter of concern to previous reviewers. The bylaws were recently amended to increase RAG terms from two to three years (may aiso be reappointed for two additional years). The Executive Committee may act for the RAG in the interim between meetings. Thirteen committees (seven categorical and six area or ad hoc) with 189 members serve the Region. The review process includes the utilization of categorical committees, and review by the Executive Committee prior to final action of the RAG. CHP is not currently involved in the review process. A major concern of | future RMPS visitors will be organizational effectiveness including the RAG's actual role in regional affairs. Adequate technical review as part of the review process will be essential. Mutual reviews and critiques of goals, objectives, plans and specific proposed activities by ARMP and CHP might be beneficial. The core staff includes 21 professionals (7 part-time) and 8 administrative/ clerical positions. Five of the professionals (1 part-time) and one office supervisor are budgeted ‘for the Phoenix Office. One professional (20% RMP and 80% Coconino County Health Department) is budgeted for Flagstaff. Subsequent to submission of the application, ARMP advised that all four unfilled positions are committed. Curriculum vitae for newly employed were provided. Job descriptions for newly acquired employees and positions to be filled would have been helpful to the reviewers. Staff expressed concern that the half million dollar core staff is direct- ing most of its energies into development of projects for which there will be insufficient RMPS support. It would seem that there would be wisdom in the Region's reassessment of its operations in relation to Arizona RMP -12< RM 00055 (5/71 Harold Margulies, M.D. os December 17, 1970 priority needs and current limited available resources. In light of - federal funding restraints, activities, including core, might be appro- priately redirected. With one exception, the current funded projects have been operational for only a few months. Many were late tooling up. A better assessment can be made at the time of the next anniversary review when more meaningful data should be available. Staff was favorably impressed by project #4, "Continuing Education in Nursing Care of Patients," an outstanding regional program with a record of success. /y fi : A f he Li “y Luther J. Says, , Public Health Advisor Grants Review Branch Action by Director < Initials Hind Date _ fel 1D | Attachments: 1) Mr. Says’, GRB, review comments RMPS staff who attended this review mceting: L. J. Says, GRB Jim Smith, RDB R. D. Mercker, GMB - Teresa Schoen, OPPE Mary Asdell, CETB , - ® Arizona RMP . PLANNING lst Year (Site Visited August 1968) Céuncil: 1967 - February 1968 - May, November 2nd Year 02 Supplement -13- REVIEW _AND FUNDING HISTORY SUMMARY 4/1/67-3/31/68 4/1/68-3/31/69 1/1/69-3/31/69 TOTAL 02 Chronic Pulmonary Disease Program - Application for 03 Year Extended with Funds Extended with Funds Extended with Funds OPERATIONAL. (Site Visited May 1969) Council: 1969 - May, August 1970 - Mareh, July Core #1 - Checklist - 20th Century Books #2 - Medical Library Network #3 - Chronic Pulmonary Disease Disapproval with advice to resubmit 4/1/69-6/30/69 4/1./69-9/20/69 4/1 /69-12/31/69 4/1/69-3/1/70 TOTAL 03 1/1/70-12/31/73 Approved Period Funded 2 years (O1) §$ (02) RM 00055 5/7} $119,045 346,125 62,983 troncememneme nasa $409,168 "Earmarked Funds" $138,095 117,208 106, 630 13,276 a $375,209 Direct Costs: 503, 300 (03) 503, 300 Aporoved Future. Level ~0- 3 years 1/ Approved in principie with no addit 3. years (01) (02) 3 years (01) (02) fonal funds 39,233 (93) $ 35,211 36,211 139,988 (03) 120', 000 112,000 RM 00055 5/71 Arizona RMP -14- #4 - Continuing Education in. 3 years (01) $ 51,895 (03) $ 84,118 Nursing Care ~ (02) © 65,807 #5 ~ Recruitment & Continuing 3 years (01) 32,621 (03) 28,379 Education Social Service (02) 57,500 #6 - CPR (01) =: 26,106 (03) 36,373 (02) 36,373 #7 ~ Continuing Education, - Coronary Care Disapproval with advice to resubmit #8 = Continuing Education for Nurses Disapproval with advice to resubmit #9 - Long-Term Continuing oe . Education for Nurses Disapproval with advice to resubmit #10 - Nutritional Care Disapproval with advice to resubmit #11 - Coronary Care Continuing Education for Nurses © Approval I (unfunded) #12 .- Coronary Care Post-grad. Courses & Seminars for Physicians, Hosp. Adm. Personnel & Trustees. Approval I (unfunded) TOTALS (01) $793,133 (03) $304,081 (02) $811,191 , 1/ Supported through Core ~ 01 year APPROVED _& UNFUNDED PROJECTS (D.C, 0) . O1 02 03 #11 $ 76,583 $ 77,405 $ 79,988 #12 _74, 812 68,648 70,640 TOTAL $151, 395 $146,053 $150,628 Arizone RMP Program Funding: Approved for Current Year ae Region __ARZZGNA anna § 311,191 Operating level in Current Year aa HX MARGE KRADEX KAA ZAIRE Ye = «= = =~ g 311,191 Current Operational Year: L/TGLL/NG first Scheduied AR appiicetion August L974 Region's optional plans: Disapproved * #1 Check list 20th Cent. Books Approved & unfunded ip funded through Core Degrée & Diploma Programs $31,034 Recommended Commitment for next year---§ 304,081 - i Ind Year COMPONENTS BY DISEASE CATECORY AOGKRGEM COMPONENTS COMPONENTS BY TYPE OF ACTIVITY on —— bee eee ce te en te Leo . \ HEART ON-GOLKS TRAINING AND EDUCATION area ' 0 / Core-$503 ,300 One goine 5 rojects #2 Lib. Network Projects tTorel $5 0 i : —s \ poral $5 397 ,891 Z $s 0 $36,211 . | % $8 382 Approved /un funded ¢ #3 Chr; Pul, Dis. | Approved/unfundes 3% Disapproved $112,000 |_____.. Disapproved ; : — ’ , CANCER #4 Cont'd Ed.- . On-going Nursing Care # Projects 0 $65,807 fc ceneeee en nee anne cee ote Total $8 3 #5 Reccuitment~- | _ DEMONSTRATION OF PATIENT CARE | | % $S 0 & Cont, Ed. | On~going ' Approved /unfunded S 2 : i # Projects Disspproved 0 taco i Total $s 5 % $8 , o [STROKE #6 CPR. | Approved /un funded. , + On-going 5 Disapproved : ; Projects 0 $36,373 L_.____._Disspnroven..- . Totel $5 eae an neonates : % $8 8 Approved-Un funded 1 Approve !/unfunded 8 -4 ET €11 C.c, Train’g _ _ Lee Disapproved | RESEARCH & DEVELOPMENT Nurses on-going ; _ KIDNEY a $76,583 Le # Projects i On; note 0 #12 C.C, Post-Grad Total $$ rojects Ed. Phys. Bosp \ % $S Toral $$ 0 ° ° . ] : rs 0 Adm, & Trustees | Mheppreved , Approved /unfunded $74,812, - Total ~ 7 Disapproved 8 151,395 “RELATED DISEASES — . - On-going a ener rnE On wet ee 4 Projects 48.373 SUPPL. REQUEST CADMINTSTRATION & PLANNING Total $8 “Core $156,650 On-eoing % $8 18% 9156, > # projects 1(Core) Approved /unfunded 8 Total $S 503 300 : Disapproved ; ~ SS ; ppre Fi3 Cont. Ed.- A tS al cunded © % . rove n , P MULT ICATEGORICAL 1} Ser. Areas i Disspproved “es ‘ - On-going $37 475 _— ; $ Projects 3 _ Total $s 153,918 Fig Cont. Ed.- Approved /unfunded i* — Physicians i Disapproved 3 $72,798 | GENERAL sine |_| #15 ECHO } Projects 1 (Core) $193,762 Total $S 593 4300 % $8 enstamarmempanson emervnemercemonnssee | Approved/unfunded 0 #16 Cont, Ed. \ 0 | Nurses of Assoc. A Privileged Commmication} . SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE ARIZONA REGIONAL MEDICAL PROGRAM . BM 00055 8 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: Disapproval of additional Core support and approval of projects with no additional funds. YEAR REQUEST . RECOMMENDED FOUNDING 02 (6 mos.) $491,719 ~0- 03 681,171 : -O» 04 645,574 ‘ ~Q- 05 (6 mos.) “ 296,298 | ~O- TOTAL $2,114,726 -O~ CRITIQUE; Tne Committee noted that the current level of support of Arizona's prograw is $811,191 (d.c.o.}, of which $503,300 (62%) is for core activities. The present request would inflate the annual -cost of core to more’ than $800,000, and should not be approved. Current support should be adequate for core activities including some pilot work on the gial access program. The Committee alse recognized the concerns that staff had when reviewing the second-year continuation application: that the objectives were not clear and that core activities were predominately project oriented. Committee concurred with staff that there would be wisdom in the Region's reassessment of its operations relative to priority needs and resources, particularly in light of RMPS funding constraints in fiscal year 71 and 72. Also, as reported by staff, the-Region has planned a retreat in late April. RMPS staff are to attend and may be helpful in guiding the Region. Arizona's primary project thrust continues to be training and education. The five currently funded projects include a library network, chronic pulmonary disease, nursing care, sccial service, and CPR. Two coronary care training projects were approved, but unfunded. The present appli- cation does not include a rank list of all projects. The projects presented represent non-categorical outreach, programs and do relate to the Regions broad goals. Correlation with operating objectives and priorities is not clear. The two Continuing Education Prograas for Physicians (Projects 13 and 14) are companion prejects that might be combined and accomplished for less costs. The "Arizona Evidence for Community Health Organization" project #15 may enhance cooperative planning ARIZONA RMP ~2- . RM 00055 5/71 and evaluation efforts with health departments, CHP agencies and others. | The "Continuation Education for Associate Degree and Diploma Nurses" project #16 has a much needed focus on Indian Health. © Committee noted that the May 1969 site visitors recognized that one of the Region's problems was need for better health care for the minority groups (136,000 Indians - 8% of the population and 187,000 Mexican- Americans ~- 11% pop.). The question arose as to the Region's current involvement and plans in this direction. In conclusion the Committee did not believe expansion of core is justified. Projects may have merit but additional funds at this time are not warranted. The Region's trienium application is due August 1, 1971 and will include a site visit to examine their total program, progress and capability. RMPS /GRB 4/21/71 © - REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) BI-STATE REGIONAL MEDICAL PROGRAM RM 00056 5/71. (Washington University) April 1971 Review Committee 607 North Grand Boulevard St. Louis, Missouri 63103 Program Coordinator: William Stoneman III, M.D. This application requests supplemental funds to support two new operational projects. This Region is currently funded at $945,233 (direct costs) for its second operational year (which is an 11l-month period) ending September 30, 1971. Due to RMP fiscal 1971 (and 72) apportionment this total is to be reduced by $60,314. For this year the Region received indirect costs of $305,046 on its $945,233 which represents an average indirect cost rate of 32%. The Region will submit its Anniversary Review Application in time for review during the July/August 1971 review cycle. REQUESTED (Direct Costs Only) © Project # & Title lst year 2nd year _—_s3rd_year Total #15 ~ Public Education $35,390 $20,988 $15,000 $71,378 Program on Harmful Effect of Cigarette Sacking #16 - Develop a Model 16,750 15,850 15,850 48,450 for Testing Physician Continuing Education TOTALS $52,140 $36,838 $30,850 $119,828 Staff has conducted its review of the Regions application for second~year ‘operational funding. While there were several programmatic and budgetary issues identified by staff, (see Addendum page) because of the nature of this application (operational supplement) the Region did not relate to these concerns. It can be assumed that information relative to the issues will be included as a part of the total program review at the time the Anniversary application is considered. BI-STATE REGIONAL MEDICAL PROGRAM = =-2.- - RM 00056 5/71. FUNDING HISTORY” Planning Stage Grant Year Period Funded (Direct Costs) Ol . 4/1/67 = 10/31/68 (19 mo.) $495,395 02 - 11/1/68 - 10/31/69 443,625 Operational Stage 01 7/1/69 - 10/31/70 (16 mo. ) $1,094,077 02 11/1/70 - 9/31/71 (il mo.) | 945,233 (of which , $64,293 is carryover) - 02 Year Listing of Funding Status of Core and Operational Projects in Bi-State RMP Project # Title — Amount Supported (d.c.) _ Through 9/31/71 0 . Core $489,296 2 . Cooperative Regional . - Radiation Therapy Program . 118,564 4 A Comprehensive Diagnostic Demonstration Unit for Stroke 46,037 5 . vA Nursing Demonstration Unit in | Early Intensive Care of Acute ‘ Stroke 55,690 8 - Cooperative Regional. Information . - System for Health Professions - 39,748 9 . Health Surveillance Education and Care Accessibility for - low-rent projects 131,605 12 C.C. Training Program for Nurses | — 64,293 a/ a/ carryover funds TOTAL $945,233 * * This amount is to be reduced by $60,314. The breakdown of the reduction is not available at this time. a BI-STATE REGIONAL MEDICAL PROGRAMS -3- RM 00056 5/71 The Region has a fairly well-balanced overall program between Heart Disease, Cancer, Stroke and Multi-Categorical activities. Background Information 1. Population: 4,9000,000 (estimated) (a} Urban 80% (b) Non-White 97% (c) Median age 31.62 2. Medical Schools (a) Washington University (b) St. Louis University (c) Southern Illinois (To open in 1972) 3. Physicians - 5021 4. General Hospitals - 178 - 22,000 beds 5. Geography (a) 66 Counties in Southern Illinois (b) 42 Counties in Southeastern Missouri SUMMARIES OF NEW OPERATIONAL PROPOSALS Requested ist year __(d.c. $35,390 Proposal #15 - To Provide Coordination for Public Education Programs in the Bi-State Metropolitan Area on the Harmful Effects of Cigarette Smoking. The Bi-State Inter-Agency Council on Smoking and Health for the Greater St. Louis area (includes 30 health or health interested agencies) requests through the Bi-State Regional Medical Program a total of $71,378 only direct costs are requested) to plan and implement this proposal for a three-year period, The program is to be physically based in the offices of the St. Louis Medical Society (without charge to the grant). The program was reviewed by the Region's Cancer Committee, the Scientific and Educational Review Committee and the Regional Advisory Group. In the latter group it received a priority rating of 250 on a 100 to 500 scale. The program has a single objective which is to improve coordination of the Bi-State Metropolitan area (six Missouri and Illinois Counties) efforts in public education on the harmful effects of smoking. According to the application this proposal will advance the Region's strategy in that the program has strong categorical disease application as well as professional acceptability and BI-STATE REGIONAL MEDICAL PROGRAMS = 4 = RM 00056 5/71 consumer appeal. Bringing education to the public, especially the younger public, on the harmful effects of cigarette smoking, the proposal will also bring visibility to Bi-State RMP and help define the program as a unifying factor in the Region's health care planning. Essentially support is requested to provide for a full-time program coordi- nator and secretary plus the usual expenses (excluding rent) who will survey existing activities and resources and then develop and implement a coordinated anti-smoking public education plan for the area. A means of evaluating pro- gress is outlined. Basically its success will be measured in terms of local © ‘support which the program receives. While the primary program target area is Greater St. Louis, the program will be made available to interested groups in other parts of the region. The proposal is presented with a descending scale budget. The second year request is solely for the support of the coordi- nator and secretary, while the third year requests a single salary for the program coordinator. The Region has been given reasonable assurance that as the program matures, its costs will be borne by other agencies. Second Year $20,988 | Third Year $15,000 Proposal #16 - To Develop a Model for Testing Effectiveness Requested / of Physician Continuing Education Programs in lst C Terms of Patient Management. $16,750 The Bi-State Region requests a total of $48,450 (only direct costa are requested ) to conduct this activity for a three-year period. The proposal was first re- viewed by the Region's Continuing Education Committee which recommended some changes. These changes were incorporated and a second review was conducted by the Scientific and Educational Review Committee. The proposal was then presented to the Regional Advisory Group. During its initial review, the RAG recommended that action be withheld: pending approval of the plan by the Illinois and Missouri State Medical Association (Society). The Missouri State Medical Association approved and commended the innovative idea. The Illinois State Medical Society recommended that the proposal be approved. Following this, and upon re-review, the RAG unanimously approved the program with a priority rating of 150, on a 100-500 scale. This is the highest priority given to any Bi-State proposal to date. The program has two objectives which are to: (1) Determine the feasibility and acceptability to practicing physicians of an experimental system for ascertaining patterns of patient management from hospital record analysis. _ (2) Test the usefulness of such patient management analysis to faculty and local physicians in planning continuing education programs. Three hospitals and their medical staffs, two in Illinois, one in Missouri, have presented formal evidence of their willingness to have hospital charts 4 ou REGIONAL MEDICAL PROGRAMS - 5+ RM 00056 5/71 analyzed to determine baseline physician performance data on selected diseases and in selected clinical hospital procedures. Using this information, problem oriented Continuing Education Programs, with each community identifying the fields of clinical practice in which it is most interested, will be developed, The proposal incorporates not only local physician design of an education pro- gram but also a mechanism for measuring the effectiveness of the program in terms of level of patient care delivered. According to the application, this proposal will relate to and enhance each of the Region's strategy components as determined by the Regional Advisory Group. Additionally, the region reports that the innovative character of this program has engendered so much interest that the region has received requests from three additional hospitals and medical staffs to be included in the program. The continuing education activity is the product of three part-time physician coordinators who have been assigned by the region to the three areas for some time. Their mission has been to develop a program based on local need rather than on subjects a distant person believed local physician would want or need. The Region's full-time Planning Director will be available for overall project coordination. Evaluation will consist of pre and post-clinical performance using the analysis of hospital charts for base-line data. $34,200 of the total three-year budget @ of $48,450 is for consultant services. These funds are to be used to purchase the necessary expertise, either from the medical schools or the com munity, to conduct the continuing education activity in the given areas. If this experiment proves successful, continued local support is anticipated through medical societies, hospitals or voluntary health agencies. Second Year Third Year $15,850 $15,850 a nd BI-STATE REGIONAL MEDICAL PROGRAM -6- RM 00056 5/71 - ES ADDENDUM | Gereral Concerns of Staff: 1. 10, The "turf" problem between the Bi- “State ‘and the Illinois Regional Medical Programs. At what level in the local review process vetoes may be imposed - -appealed? Staff would be interested in: knowing the type of activities and ‘the number of proposals which have been disapproved in the local | ' review process, Evaluation methodology. Staff was not convinced that the data collection system proposal would actually strengthen the planning efforts of the Region. Assignment of a field Coordinator to the Springfield, Illinois area in view of jurisdictional and geographic ‘problems which are about to surface. Contributions being made toward the goals and RMP objectives by the six categorically assigned Associate Directors to the two medical schools. Lack of impact operational projects have on the improvement of the Delivery of Health Care. How some of the minimal requests for carryover ($200 - $350) were processed through the local review system. _ The Region be given consultation concerning Council's July 1970 decision as relates to the stipends, travel, etc., for short-term ‘traineeships... GRB/3/11/71 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE BI-STATE REGIONAL MEDICAL PROGRAM RM 00056 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: The Review Committee recommends that this supplemental application which requests support for two new projects be partially supported as follows: . RECOMMENDED YEAR REQUEST FUNDING Ist $52,140 $16,750 2nd 36,838 15,850 3rd 30,850 15,850 “TOTAL $119,828 $48,450 CRITIQUE: The Committee noted that the Bi-State RMP will submit its anniversary review application in time for review during the July/August 1971 review cycle. Also, the reviewers were satisfied that the Region will relate, in this future application, to the con- cerns of staff which were raised during staff's review of the Region's second year continuation request. Since this optional application included only two projects, the Committee did not have an opportunity to study the potential impact - on the entire program. It was concluded that the adding of Project #16- To Develop a Model for Testing Plivsician Continuing Education would add strength and balance to the Region. Members of the Committee believed that the proposed activities were innovative; that the pro- gram was presented in a proper cooperative setting; that the fiscal request was reasonable; and thet further plans for. the program include continued support from local sources. Conversely, the Committee viewed project #15 - A Public Education Program on Harmful Effect of Cigarette Smoking as a program which contained nothing new, lacks innovation and noted that many similar anti-smoking programs have already been supported across the country. It was concluded that this project would not be a priority for use of RMP funds. - , GRB/RMP § 4/21/71 - © REGIONAL MEDICAL PROGRAMS SERVICE CALIFORNIA Regional Medical Program RM 00019 5/71 (Special Action) FOR CONSIDERATION BY APRIL 1971 REVIEW COMMITTEE STAFF INFORMATION This project was one submitted by the California Committee for Regional Medical Programs for the November/December 1969 review cycle. The Lockheed Corporation, by means of a contract with Area I, collaborated with personnel at Mt. Zion Hospital in the development of an electrocardiographic sur- veillance system which monitors silently a large number of patients simultaneously and continuously. The monitoring is silent until a deviation occurs, and there are no practical limitations to the number of patients or their locations. A site visit team, which included an expert in biomedical applications of such techniques, visited the Mt. Zion Hospital in October 1969, to observe the system in action. The team found the project interesting from a number of standpoints, but had some concerns, largely technical, which were later relayed to the region. The proposal was also reviewed by the ad hoc © Cardiovascular Panel and the following concerns reflect the opinion of all reviewers, including the National Advisory Council: Ll. the educational aspects of the overall program were not clearly described; 2. evaluation methods were thought to be vague, with no record system to describe events monitored; 3. the validity of alarm signals was not clear; 4. the contribution of Lockheed Corporation to further development and de-bugging was not specified; and 5, the system had not received sufficient time for more extensive testing in a clinical setting. The team felt that approximately a year would be required to de-bug the system compketely and allow the Mt. Zion personnel to test it before extending it to more remote hospitals in Area I. The Lockheed Corporation has offered to assume costs for instrumentation and engineering for three years at a total cost of $495,300. CCRMP feels it is important for this program to continue to carry the label of RMP in order to assure that certain aspects concerned with patient care services, regiona- lization and professional education, etc., are retained in the program in a meaningful way. The amount to be allocated from CCRMP funds is $35,446 (d.c.) for personnel. A cost breakdown prepared by Lockheed is a part of the revised application, and provides a written understanding of terms of the arrangement. Special Action - page 2 The revised proposal was submitted to Doctor J. Brancis Dammann, Professor of Pediatrics and Biomedical Engineering, who served as consultant for this project on the site team of October 1969.. Dr. Dammann very graciously agreed to review the revised protocol for the Mt. Zion program and his report of March 2, 1971 is attached. _ RMPS/GRB 3/17/71 ‘ . UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE § UNIVERSITY OF VIRGINIA HOSPITAL CHARLOTTESVILLE. VIRGINIA, 22901 6... OF PEDIATRICS March 2, 1971 Division of Pediatric Cardiology Research - Box 218 Jessie F. Salazar Public Health Advisor Grants Review Branch Health Services and Mental Health Administration . Rockville, Maryland 20852 Dear Mrs. Salazar: Per your request, I have reviewed the updated and revised project for patient monitoring at Mt. Zion Hospital in San Francisco, I believe that the applicants have satisfied all of the site visitors major objections © to the program as it originally was set forth. Therefore, I think it very appropriate for the Regional Medical Program to support it as it now stands. Three major changes in the program have been made which answer most of the site visitors concerns. First, I deem it very appropriate indeed that Lockheed has agreed to pick up the expenses of building the system for trial at Mt. Zion Hospital. It seems to me to put the association of medicine, government and industry ona much more solid base, whereas government picking up the expense of the system did not appear to be justifiable. Secondly, the decision to restrict the systems trial in the field to Mt. Zion Hospital until after a total evaluation has been made also is wise. The system will get a solid evaluation before additional sums of money are spent to develop additional systems. This is a logical way to proceed. Finally, the applicants have recognized the need for a sound objective assessment of the value of the system in the patients at Mt. Zion Hospital. The results of that evaluation ought to be meaningful indeed, and ought to give a firm basis for decisions concerning construction Vyeg Ly cwl Meret ag Chyrg Haye Bats ahs Sega Sy ae See vd Diesen of Reahacet Be dis. A Praga of additional units, modifications to be made in the units and the benefits that might be expected from expansion to other hospitals. . This plan for evaluation of the system as it was designed, takes care of objections that I voiced concerning the system. A complete study of all signals and alarms with emphasis on false alarms, failure - to alarm and true alarms will establish whether the system can carry out what it was designed to do or whether changes in design approach | are indicated, Since the system is unique and my concerns were primarily theoretical, it certainly deserves a comprehensive trial, provided of course a complete evaluation is carried out. I think it very likely that such an evaluation will be carried out and therefore, I think. it very appropriate that the program continue as outlined. To recapitulate, I believe that the changes that have been made in this program since our site visit meet our objections and that therefore the program should be supported as it now stands. Considering the manpower shortage and the potential value to community hospitals, if the trial at - Mt. Zion proves strongly positive, I think this program should be supported at a high priority. I would very much appreciate personally if it is possible hearing how this program evolves, whether it is supported and what the results of the evaluation are. Thanks for. letting me review this application. If there are further remarks that you need from me, please let me know. Sincerely yours, IN SON ‘ “oe on J. Francis Dammann, M.D. Professor of Pediatrics and Biomedical Engineering JFD/vms Pe ‘(A Privileged Communication) , SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE CALIFORNIA REGIONAL MEDICAL PROGRAM ° RM 00019 5/71 SPECIAL ACTION #1 FOR CONSIDERATION BY MAY. 1971 ADVISORY COUNCIL Project #41 (Revision 2) - Area I - Patient Monitoring Recommendation:- Committee recommended approval of the proposal with no additional funds, t Year Requested Recommended 01 $35 ,446 Approvaj 02 36,178 Approvel Total $71,624 (Direct Costs) Background: The Committee briefly reviewed the history of this proposal which began in 1969. It was reviewed on site in October 1969 and was recommended for return for revision because of several technical concerns. Council concurred. The proposal was revised and resubmitted to the July 1970 review cycle at which time Council concurred with the recommendations at the ad hoc Cardiovascular Study Panel that the pro- posal required further revision, At that. time the application was still believed to be unapprovable on technical grounds, Critique: The revised proposal appeared to satisfy the specific concerns which had been relayed to the Region. Some discussion revolved -on the point of the value of the evaluation effort RMPS is asked to ‘support. The original proposal included a budget approximating $260,000. The revised version requests only $35,446 mainly for personnel since Lockheed has agreed to assume the costs for instrumentation. The’ reviewers felt that this joint industry - medical effort provides a solid,- practical basis for development ‘anck. that CCRMP's proposal to evaluate the clinical usefulness of the system is an important aspect of the undertaking. Further, the reviewers agreed that the region's endorsement (RMP label) for this system is also important. > Drs. Mitchell Spellman, Gerald Besson, - John Mitchell and Donald Brayton wete not present during the discussion of this application. . « RMPS /GRB/4/26/71 REGIONAL MEDICAL . PROGRAMS SERVICE ‘CALIFORNIA Regional Medical Program RM 00019 5/71 (Special Action #2) FOR CONSIDERATION BY APRIL 1971 REVIEW COMMITTEE California RM 00019 "Cooperative Planning Effort of Regional Medical Programs and Model Cities for Training in the Allied Health Professions" | This is a new progrem to be based in Core Staff activities in Area I, San Francisco. It is an outgrowth of Regional Medical Program participation in health planning for the Richmond Model Cities Program. There are six Model Cities in Area I, and this request ig made for support to explore solutions to the health service problems, particularly in the field of training of allied health professionals. This is an 18-month proposal requesting $73,349 direct costs for the first year and $39,333 direct costs for the remaining six months, GRB/4/19/71 To ore gy SUMMARY OF REVIEW AND CONCLUSION OF: . - APRIL. 1971 REVIEW COMMITTEE CALIFORNIA REGIONAL MEDICAL PROGRAM RM 00019 5/71 SPECIAL ACTION #2 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL “Cooperative Planning Effort of Regional Medical Programs and Model Cities for Training in the Allied Health Professions" ~ Area I Recommendation: Committee recommended that the request be returned for revision with advice as enumerated below, Year “Request Recommended o1 $ 73,349 -0- 02 39,333 “~~ Total $112,682 Direct Costs -0- Critique: The reviewers agreed that the proposal was a well written planning document, but that therein lay an overriding negative factor, .The proposal represents a planning effort while the Model Cities endorsement fosters an action plan. There is no action target to be reached in the 18-month plan. Committée believes the proposed program area of involvement is of high priority, and if the real "product" is the training of allied health professionals, then the methodology should be redirected~-not to employ "Planners" but to develop steps of action to reach the people in the target districts, The Committee suggests that the Region arrange its own "site visit" method, drawing on regional consultative resources such as Dr. Stanley S. Skillikorn in Area III (for his. planning for health delivery improve- ments in thée-Gardner district of San Jose), and Dr. Mitchell Spellman in Area IX (for functional experience gained by the Drew Postgraduate Medical School planning). Hopefully, the hext step can be a more affirmative action plan, There was consensus that the proposal would benefit by a "phased" approach. During phase one, staff would be hired, utilizing consultants, and initial cooperative arrangements should be firmed up. Phase two would involve careful review of the Task Force (site visit) recommenda- tions by CCRMP staff and RAC. Phase three would preSent the recommendations of the Task Force to the Model Cities Health Council and other appropriate agencies for action and implementation. Staff Note: February 1971 Council approved the use of Developmental Component funds by the California RMP. The Region will submit a triennial application May 1, which will be reviewed by the July Committee and August Council.” Drs. Mitchell Spellman, Gerald Besson, Jobn Mitchell and Donald Brayton were not present during the discussion of this application. REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) IOWA REGIONAL MEDICAL PROGRAM RM 27-03 5/71 University of Iowa April 1971 Review Committee 308 Melrose Avenue Iowa City, Lowa PROGRAM COORDINATOR: Harry M. Weinberg, M.D. This application requests supplemental funds to support five new operational projects. The Region's Triennial application is due in August and will be reviewed by the October Committee and November Council. Requested (Direct Costs Only) Project # and Title 01 Year 02 Year 03 Year Total #17-Laboratory Improve- $ 45,182 $ 35,337 $ 25,141 $105,660 ment Program #18-Minowa Continuing 45,200 45,192 46,275 136,667 Education #19-Renal Failure Manage- 80,317 83,508 87,839 251,664 ment. Training #20-Organ Procurement: 48,920 35,272 36,719 120,911 a Preservation #21-Multimedia Nursing 108,737 35,500 22,500 166,737 Education Totals $328,356 $234,809 $218,474 $781,639 The last staff review in January 1971 noted that the region has made considerable progress in the following areas: The Core staff, for the first time since the inception of this Region is now fully staffed; the Regional Advisory Group which has been increased from 46 primary and alternate members to 76 primary and alternate members appears to be a truly regional cohesive group which shows great strength and ability in the Region's decision-making process and in providing guidance to the Region: and in the development of cooperative arrangements with Community hospitals, and the involvement of the various disciplines of the allied health professions, practicing physicians and the University of Iowa Clinical faculty in the planning and decision-making process of the IRMP. The operational activities are primarily in the heart and stroke areas, Staff recommended approval of the request for continued funding for the 03 year at the commited level of $651,417. However, due to 1971 fiscal contraints, the region will be funded in a reduced amount of $596,047 (d.c.o.) Iowa Regional Medical Program -2- RM 27-03 A FUNDING HISTORY . s PLANNING STAGE Grant Year Period Funded (d.c.o.) 01 12/1/66 - 1/31/68 (14 months) $214,000 — 02 2/1/68 = 11/30/68 (10 months) 213,000 OPERATIONAL STAGE 01 7/1/68 ~ 1/31/70 $455,000 02 2/1/70 - 1/31/71 736,673 03 (Current Year) 2/1/71 -12/31/72 (11 months) 596,047 Following is a listing of the 03 year funding status of Core and the Operational Projects in Iowa RMP: Project No... | Title Amount Supported , Thru 12/31/71 (d.c.o.)) #1 Core $290,070 * #2 & #3 Central Stroke Educa- tion and Stroke Management 134,930 #4 Training Program in Cardio- 3,985 * Pulmonary Resuscitation #5 Coronary Care - Supervision Training for Physician & Nurses 65,712 a“ r #11 Pediatric Cardiology Training 51,400 ‘ Program #12 Cancer Educational Program 2,355 * #13 ss Mobile Intensive Care Unit 37,460 #14 Cardiac Auscultation Training for Physicians a, 10,135 * Total , | $596,047 * Members of staff have learned that the amounts shown reflect the revised budgets for these components. The reduced amounts were approved by the Iowa Regional Advisory Group on February 28, 1971. It was also learned that project #4 and #12 will terminate as of April 1, 1971. It was further indicated that the Iowa Heart Association would assume full funding of project #4 at that time. s Le Iowa Regional Medical Program -3- RM 27-03 5/71 SUMMARY OF NEW OPERATIONAL PROPOSALS Project #17 - Laboratory Improvement Program oi 02 03 Requesting _7/1/71-6/30/72 7/1/72-6/30/73 7/1/73-6/30/74 All Years Direct Costs $45,182 $35,337 $25,141 $105 ,660 The State Hygienic Laboratory through the Iowa RMP requests three-year funds for a program which has been funded through the Office of Compre- hensive Health Planning since February 1969. The program is designed to increase the general level of competency of clinical laboratories in the Iowa Region. The ultimate goal is to improve health care delivery at a local level by a comprehensive continuing education program for clinical laboratory personnel within the districts and sub-districts of the Iowa Region and to have available to all Iowans, adequate, accurate and totally capable clinical laboratory practices regardless of the size on geographic location of their local facility. The specific aims of the proposal are: (1) To determine the quality of performance of Jaboratories in the Iowa Region by utilization of national and local proficiency testing programs, (2) To improve the quality of laboratory services through a comprehensive continuing education program with the cooperation of the Iowa Association of Pathologists. (3) To assist participating facilities to provide standardized equivalent laboratory services to all disciplines. (4) To provide consultation services to laboratories in the Towa Region. In addition to the State Hygienic Laboratory, the Iowa Association of Pathologists, the University College of Medicine, the Iowa State Health Department and participating Community hospitalsare involved in this activity. Project #18 - Areawide Continuing Education for Health Care Personnel in the Minowa Health Planning Area O1 02 03 Requesting _7/1/71-6/30/72 7/1/72-6/30/73 _7/1/73-6/30/74 All Years Direct Costs $45,200 $45,192 $46,275 $136 ,667 iowa Regional. Medical Program - ~4 ~. KM Z£/-UD sr This proposal is an outgrowth of interest among six Northeast Iowa counties to coordinate efforts to supply a continuing medical and health science educational program for health care personnel of their combined areas. The project is designed to demonstrate the feasibility of such an undertaking in a rural environment, where the accessibility and adequacy of continuing medical education currently fall far short . of satisfying the needs of health care personnel. The project proposes to: (1) identify and improve continuing educa- tion programs for physicians and allied health care personnel; (2): identify unmet and fill needs for continuing education; and (3) com- bine or link together hospital and other related agency or community programs. The continuing education programs planned under this pro- posal will be primarily for the counties of Howard, Winneshiek, Allamakee, |, Chickasaw, Clayton and Fayette; however, personnel from contiguous counties in Iowa, Wisconsin or Minnesota will, if interested, be permitted to participate in any of the activities. ’ The project will be based at the Area. I Vocational-Technical School at Calmar in Winneshiek County. Other agencies involved in the devel- opment and implementation of the program include the-Minowa Area Health Planning Council, The University of Iowa College of Medicine, the Mayo Clinic, the Adolf Gundersen Medical Foundation im Wisconsin and four hospitals in the six-county area. The Minowa Area Health Planning Council will provide overall direction of the projett throygh a 12-member steering committee who will act in an advisory gapacity in surveying the medical community to determine the educational needs, setting priorities and developing currictla.. The University of Iowa College of Medicine, the Mayo €lffiic, the Adolf Gundersen Medical Foundation will provide teaching personnel and consultative services, the latter being utilized in establishing priorities and developing curricula. The four hospitals have agreed to place the coordination of their in-service programs under the project. A Project Director will be employed. Local funding of this project will be accomplished by progression (over a three-year period) in the tuition charged to participants involved in the program and through charges imposed on the hospitals for coordination and provision of in-service training. It is expected that many of the on-going programs can be incorporated with the Community College structure and financed by tuition charges and school tax funds. #19 - Renal Failure Management Training Oo} 02 03 Requesting __ 771/71-6/30/72 7/1/72-6/30/73 7/1/73-6/30/74 All years Direct Costs $80,317 $83,508 $87,839 $251,664 Iowa Regional Medical Program -35- RM 27-03 5/71 {This proposal represents part of a cooperative effort of a number of encies in Iowa to organize an effective plan for the care of the tient with uremia. Involved in this development are the University edical Center-including the University of Iowa, University Hospitals, and the VA Hospital and the Regional Medical Program; a number of communities of the State; insurance underwriters; voluntary health agencies; the Legislature; the State Department of Health; and many private citizens. The specific aims of the project are: 1) To provide practicing physicians a course of intensive study in clinical nephrology. The course will vary from one week to six months. A total of twenty (20) physicians are expected annually in the one- week course and two physicians for one month or longer. Participants will be capable of improving the general level of care of patients with renal disease and hypertension. With adequate support they would be able to manage small dialysis centers, stations for home dialysis supervision and instruction, and units where cadaveric kidneys might be retrieved. 2) To train nurses to staff areawide nephrology units (satellite centers). Two types of educational programs will be offered. The first, which will be four weeks in length, will be a basic indepth educational pro- gram to prepare nurses to care for patients receiving hemodialysis @ to supervise other nursing personnel. irty (30) nurses will be trained in the preparatory hemodialysis pro- gram in the first year; twenty-four (24) in the second year and eighteen (18) in the third. Ten (10) nurses will receive training in the devel- opment and administration of a hemodialysis training program during the first year and twenty (20) will be trained in the program to deal with home dialysis and the care of the patient with renal homotransplant. A second educational program -consisting of workshops will provide con- tinued development of nurses in the community involved in caring for patients on dialysis or those who have been transplanted. 3) To establish workshops for technicians, social workers, dietitians and public health nurses to orient them to special problems presented by patients with renal disease. Annual workshops will be held at the University of Iowa Medical Center for this group and at least one visit will be made annually to each of the satellite centers by members of this group to observe problems associated with the satellite centers, suggest solutions and promote communications within the system. Some of the programs will be interrelated with those of physicians and nurses, but special problems in each group will be dealt with separately. The applicant is requesting a total of $13,389 for stipends to be paid to those physicians attending the program for intermediate periods of from one to six months. The stipends will be paid on a monthly basis. .owa Regionat Medical rrogram -o- hte ep wo pe #20 - A Program of Human Organ Procurement and Preservation for use in Clinical Transplantation : 01 02 / . 03 re Requesting 7/1/71-6/30/72 7/1/72-6/30/73 7/1/71-6/30/74 All years $48,920 | $35,272 $36,719 | $120,911 The overall goal of this proposal is to better utilize existing sources ‘of organ donors in order to make renal dialysis and transplantation available to more uremic patients in the Iowa Region. Sponsored by-the University of Iowa-Veterans Administration Hospital Renal Program, the major objectives of this proposal are: 1) to train organ preservation technician by two months on-the-job training; 2) to develop for clinical use an improved system of organ preservation by continuous cold perfusion; 3) to organize within community hospitals (five initially) cadaver organ recovery teams of physicians and nurses, thereby maximizing organ recovery potential, this will be coordinated with Project #19; 4) to extend cooperation to other regions, continentwide, in order to exchange and evaluate a greater number of well-matched, viable organs. The IRMP will also assist the Kidney Foundation in launching a campaign to stimulate public understanding of the need for organ donors. The evaluation activities will be in collaboration with those described in the preceding proposal "A Program to Train Physicians and Nurses in Renal Failure Management." -The interrelationship of these two pro- _posals and their combined impact on renal disease in the Iowa Region is tied to an increased capacity to perform transplants in Iowa. The applicant hag requested operational funds for a total of three years. However, as the program develops in clinical service, income will be generated and will be applied to the costs of continued opera- tion of the program. The extent to which the proposal will be able to support itself will depend on the number of organs recovered and transplanted each year. The applicant states that a bill has been introduced in the Iowa General Assembly that proposed a fund to assist Iowa residents in the payment of medical bills arising from human organ transplants and if approved, will enable this activity to become self- supporting. Towa Regional Medical Program -7- KYL 29eua ogre #21 - Multi-media Nursing Education . o1 02 03 Requesting 771/71-6/30/72 7/1/72-6/30/73 7/1/73-6/30/74 All Years Direct Costs $108,737 $35,500 $22,500 $1.66, 737 The Iowa Hospital, in cooperation with the Department of Nursing, Marycrest College, Davenport, the Department of Nursing, the Mercy Hospital, Iowa City and the Audiovisual Center of the University of Iowa proposes to upgrade nursing care in the Iowa Region by utilizing a self-instructional multi-media program of continuing nursing education. The proposal addresses itself to health care facilities providing nursing care for patients with cancer, heart disease, and stroke during all phases of their illness. These include general hospitals, extended care and convalescent care facilities, nursing homes and outpatient clinic. The program has as its target population, the Registered Nurse. The specific aims of the project are to: 1) develop a programmed course manual and multi-media materials to be used in a self~- instructional continuing nursing education program; 2) demonstration in five commmity hospitals the feasibility of the programmed, self-instructional multi-media package for continuing nursing education; 3) evaluate the program continually in order that the program format and content may be adopted to changing needs and demands; 4) make available to health care institutions and and agesiceles in the lowa Region a self-instructional multi-media prograt, of ¢ontinuing nursing education and; 5) evaluate the im- pact of the project nursing attitude and behavior in the Iowa Region. Some of the expected advantages of this approach are that it will poermit each hospital or health facility, regardless of size or location to update the knowledge of its nurse prac~ titioners Without sending them away and losing their services for vary4ng Periods of time. It reduces the cost of carrying on an effective continuing education program, because it elim- inates the use of live teachers to keep repeating a program. Additionally, it will allow an inservice educator to use her time more productively and it will encourage recruitment of inactive nurses back into nursing by offering them an opportunity to up- date their skills at their own pace. The applicant states that the proposal will become self-supporting after RMP funding has been terminated. RMPS/GRB/3/16/71 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE IOWA REGIONAL. MEDICAL PROGRAM RM 00027-03 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL ' RECOMMENDATION: The Review Committee récommends that no additional \ funds be provided for this application. The Ad Hoc Renal Panel, on the other hand, believed one of the two Renal proposals, which were a part of the application, was fundable at a reduced level. DIRECT COSTS ONLY YEAR REQUEST : “RECOMMENDED lst yes $328,356 oO -0- 2nd year ‘ 234,809 -0- 3rd-year 218,474 30 = TOTAL $781,639 ~ 0 - "CRITIQUE: The reviewers noted that the Iowa Regional Medical Program will submit its Triennial application for October/November 1971 Review Committee and Council. The Review Committee was in agree- ment that the Iowa RMP has a dynamic program and the five proposed activities, although lacking innovation, are essentially excellent projects. However, both the primary and secondary reviewers were con- cerned that the proposals are not congruent with the emerging goals and objectives of Regional Medical Program Services, as described in the President's Health and Budget Messages, and that providing funds to support these activities would not be a priority use of RMP funds. Some of the Committee felt that disapproval of the projects was anti- thetic to the concept of decentralization and lwcal goal-setting. In reaching a recommendation, eleven (11) of the reviewers were in agreement, while three (3) members opposed and one (1) member abstained. a% Towa RMP -2- RM 27-03 5/71 Renal Projects » During its review of this application the Committee did not have .the benefit of the recommendations of the Ad Hoc Panel on Renal Disease which met concurrently with the National Review Committee. The Ad Hoc Panel on Renal Disease believed that Project #20 A Program of Human Organ Procurement and Preservation for use in Clinical Trans~ plantation was. technically sound and worthy of support at a reduced total amount of $43,500 for the lst year. Specifically, the Panel believed reductions were warranted in the categories of personnel, consultant services, supplies and equipment. Regarding the 2nd and 3rd years of support, the Panel believed that actual funding would have to be determined by the progress made during the ist year of the project. . #19 - A Proposal to Train Physicians and Nurses in Renal Failure Manage- ment, The Panel did not believe that this project should be supported. The proposal appears to be a poorly conceived effort to provide support for the training of renal fellows which is not appropriate under RMPS policy. Further, thé Panel suggested that the Region may wish to direct its efforts in the area of the development of home dialysis training programs. Miss Kerr was not present during the Committee discussion or action on this application. RMPS/GRB 4/23/71 KANSAS SUMMARY Table of Contents Fiscal Information Geography and Demography Regional Development Organizational Structure and Processes Regional Objectives Developmental Component Application Core Continuation Projects Renewal Projects Approved but Unfunded Projects Supplemental Projects ao] « . vuyvuVUUUUOUUY 1 Cc Wu re . 10 10 12 12 14 16 - REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication ) KANSAS REGIONAL MEDICAL PROGRAM RM 00002-05. 5/71 3909 Eaton Street April 1971 Review Committee Kaneas City, Kansas 66103 . Program Coordinator: Robert W. Brown, M.D, This region is currently funded at $1,633,600.{direct costs) for its third operational year (which is an 1l-month period) ending June 30, 1971. It aubmite a triennium application that proposes: I - A Developmental Component Il - The continuation of Core and 2 ongoing activities Ill - The activation of 4 Council approved but unfunded activities Iv - The renewal of 6 activities V - The implementation of 1 new activity VI - The termination of 2 activities The Region requests $2,244,073 for its fifth year of operation, $2,158,176 for the sixth year and $2,503,999 for its seventh year. A breakout chart identifying the components for each of the three years follows. A site visit is planned for this region, and staff's preliminary review of the application has identified several issues for the site visit team's. consideration. These are also covered briefly in this summary. FUNDING. HISTORY Planning Grant Year Period Funded (d.c.0.) 01 7/1/66 - 6/30/67 . $180,520 02 7/1/67 - 5/31/68 205,891 Operational Program Grant Year Period Funded (d.c.o.) 01 6/1/67 - 5/31/68 § 592,248 02 6/1/68 - 5/31/69 1,644,819 03 | 6/1/69 = 7/31/70 2,096,926 (14 mos.) 04 8/1/70 - 6/30/71 1,633,600 (11 mos. ) 05 Future Commitment 1,353,159 06 Future Commitment 1,025,702 REGION KANSAS | CYCLE 3M 00002. 5/71 1Z4/S zO0000 Wu BREAKOUT OF REQUESS__ 63 PERIOD (Triennica) ECENTENCING | VARNTOUSLY (NER T vo DACTINITIES RENEWAL APPR/UNEIN, [ACLINITIES INDIRECT TOTAL : DEVELOPMENTAL COMPONENT 3 | 4 463.340 $ 163.260 02 & 162.360 cone oo. gryimaio__! | im he p71 410_16325.241 11.496, 641 Efucational Programs - . ; i : ‘ ‘ i i ' #1 Great Bend : 'g129,574 | ! 139,574 | 36.339 | 175,906 Q Sh = Cardiovasculer Nursing 136,441 ; ‘ 7 136.447 (32. 647 | 175,088 “ER - CE for Cardiac Care 39,526 20.526 | 10,520° : 59,056 i oR ~ Nurse Retraining. : 32,074 ; ; 22,074 9,864 41,938 ; Cerebrovas., & Neuro. : Po ; , ie : : : a i #21R - Nurse Training . ' 38,345 ve! : 32,345 } 11,943 | 50,288 “423R - Medical Librery Syst. | 61,683 7 61,683 | 7,278 : 68,961 “#32R - Institute for Dietitians 12,000 12,000 1,599 13,599 , #38 - Med. Record Clerks Cé 6,415 . i. 6,415 ! -0- 6,415 : #40 = Comprehen. Nephrology ' $133,673 133,678 {23,933 157,611. ‘#41 - Cancer Info. Center : i 82,803 ‘gy 803 | 19,671 : 102,474 ‘#42 - CE Cancer Care : a 64,262) ' 64,262 | 8,692 72,954 7 #66 - Nurse Clinician —_ : 125,212 | a 125,212, : 12.,786 137,998 “#05 - Model Cities ‘ “> 4 937,290 37,290 noe | 37,290. TOTS, $1,314,266 $323,202 _ $405,955 $200,650 $2,244,073 ' $506,504 ‘92,750,577 dWu sesugy REGICN__ KANSAS : TOTAL $1,350,881 $179,292 | $389,579 $2,158,176 $509,079 ; CYCLE RM O00020 5/71 BREAKOCT OF REQUEST c6 __PERTOD (Triennium) CONTINL ESS | "PREVZOUSLY | NEW i BENE ST ACTIVITIES "RENEWAL VAPPR/UNTIN, AGPIVITIES ‘ OIRECT TNOTRICT TOTAL ‘ i ; DEVELOPMENTAL : : $201,134 $ 201,134 - -0- "$201,134 ‘ : : ! i : : : ; : 3 ! ‘ a : | _ CORE . $1,350,881 | - 1,350,881 :$. 393,400 1,744,281 : ; #1R : $110,446 | ; 110,446 (35,514 145,960 i i : : : i i : #6 wen : i ‘ _ eos : | 7 i ; ; ; ' HER (sen j sos : #98 —— : a 4 | ° #21R i oss i ‘ : “-- “-- 3 #23R j 68,846: | 68,846 ' 5,481 . 74,327 i i ; 1 #32R _ i ieee bee ee i po i | #38 ee | L. beans ! ‘840° ' $108,081 108,081 | 26,078 134,159 #41 ‘gg 358 ! gg.358 {21,435 109,793 arr : ; 7 — ‘ : i 1 . 7 t i ‘ ‘ #42 570,957 ' 70,957 | 13,238 ' 84,195 : : : : : ys 1 : $44 / 122,183: 122,183 . 13,933 5 136,116 7 rr #45 : : 37,290 37,290 | : 37,290 : $238,424 $2,667,255 14/S zoooo We du sesuey “t- BREAKOUT OF REQUEST __O7..., PERECD . . RM 00002 5/71 aWu sesuey he ThA? 7 . = Vr - ALD YEARS 1 ALL YEanS 4 ; ACTIVITIES 4 ; ; ACTIVIT “SS DIRECT INDIRECT j TORAR DIRECT 1 TOTAL DEVEL. | | | $234,628 's 234,628 -0- 5234628 8 599,122: is 599,122 CORE $1,620, 083 | 1,620,083|$ 475,855 2,095 08 | 4,142,374 | 5,336,860 3 #1R | $217,015 - 117,015 37,338. 154,353 367,035 | 476,217 | ae i nae | a wee [oot | —_ : 136,441 175,088 #9R | --= | | --- wee I 32,074 , 41,938 |, | { i : _ . { te ' oe #21R i. lone dS foe bene gg 445 | 502288 ! #23R | 80,596 80,596: . 6,630 | © 87,226: 211,125 230,514 : [pre ef | ee be 132,000 | 232599 re ee eee Cee | oe sts al 1 #40 i 410,746 | 114,746) 28,415: 143,161. 356,505 434,932 #41 i 101,314 | 101,314! 93,354! 124,668' 272,475 i 336,935! | , i i 1 thee ot : Tt i i #42 | | 72,172 72,172) 13,695; 85,867; 207,391 ' 243,016 eo ‘ ~T : - : i ‘ ; - : . 244 , 126,155 ; 126,155; .. 15,180, .141,335:' 373,550__ 415,449 3 ; | \ : : i | ee : “1S | #45 ' 37,290 | 37,290! -0- 37,290. 111,870: 221,870 | * ee > | i ie i | of, a Z . {a : : t : : : . : i i 1 4 . _ - ' “i : : t | , : i , . vt Y i cota, | $1,620,083 | g197,611 | $414,387 | $271,918 . $2,503,999 $600,807 “$3,104 #66: $6,906,248 $8,522,298 | po fo ba} od tr ok | | an po aS ‘ fo. - Kansas RMP -5- RM 00002 5/71 Geography and Demography The Kaneas RMP boundary is the State's. A population of 2,200,000 is contained in the 82,000 square-mile area. The Region is primarily rural; its two largest cities are Kansas City and Wichita. The Kansas RMP shares boundaries | with the Nebraska, Colorado-Wyoming, Oklahoma and Missouri RMP's. The relationship with the Missouri RMP's activities in Kansas City, Missouri, as well as the medical care flow patterns between the two political units, have been difficult to determine and appear to fluctuate from year to year. A liaison committee to coordinate the operations of the two RMP's in Kansas City was established several years ago, but neither RMP mentions it in their present applications. The state of Kansas has one medical school - the University of Kansas and 34 schools of nursing, including diploma, associate degree and L,P.N. schools. There are also 61 schools of allied health. Kansas is served by 2,218 practicing physicians (there are 2,442 M.D. 's in the state), 184 doctors of osteopathy, and 8,323 active nurses (there are 11,001 R.N.‘'s). There are 173 hospitals in the state; of these, 15 are state, military or V.A. Regional Development RMP planning in Kansas began with a Governor-appointed Commission who selected a Regional Advisory Group and named Dr. Mills as Coordinator. The planning grant was awarded in July 1966. During the first operational year Dr. Charles Lewis was appointed permanent Coordinator and a site visit was held. Both reviewers of the early planning application and site visitors commented on the close ties of the RMP with the medical school. The medical school served as both the grantee agency and fiscal agent, representatives of the medical school served as RAG Chair-~ man and in charge of important core functions, and early efforts in continuing education activities appeared to be a continuation of already existing activities of the medical school. Conversely, representation on the RAG and involvement in the program of community interests, minority groups and other agencies needed. to be expanded and strengthened. This Region was one of the first to submit an operational program. The Region received funds for projects in April 1967. One of the first approved projects was the Great Bend Educational Program, which was to serve as @ model for developing continuing education programs to attract and keep health care personnel in the rural and small town areas, developing linkages to provide better care to peripheral elements and increasing the overall capacity of providing care. The project, supported since June 1967, requests an additional three years of support in this application. Other projects approved during the first operation year included: #2 - Reactivating Nurses (Great Bend ) #3 - Circuit Course for Active Nurses as Mandi acanastiawe Muven Training Kansas RMP -6- . RM 00002 5/71 #5 - Cancer Detection #6 - Physical and Occupational Workshops #7 - Cardiovascular Work Evaluation All but Project #4 have been terminated. During the second and third years a large number of continuing. education - courses for physicians, nurses and allied health personnel were submitted and approved. The following is a listing of the activities and their present - 8 status: , , #8 - Continuing Education for Cardiac Care Renewing $ #9 - Metropolitan Kansas City Nurse ' Retraining Program . Renewing #10 - Health Data Bank Terminated #11 - Self-Instruction Centers Terminated #12 - Training Program for Cancer of the . Gastrointestinal Tract Withdrawn #14 - Perceptual Motor Dysfunction Assesment and Treatment Terminated #15 - Physical Therapy Workshop Terminated #16 -- Therapeutic Nutrition Terminated > #17 - Cancer Chemotherapy Seminar oe Terminated #20 - Continuing Education Program for ‘Occupational Therapists Terminated = _ oe #21 - Cerebrovascular and Neurological Nurse Training Renewing #23 ~ Kansas Medical Library System Renewing #24 - Food Service Personnel Using the Dietary Consultant Approach Terminated #25 - Coordinated System for the Continuing : Education of Medical and Paramedical Transferred Personnel ~ to Core #26 - Cancer-Care Continuing Education : Program Terminated #28 - Seminar on Basic Medical Librarianship Terminated #29 - Kansas City Council on Health Careers ; . Manpower Recruitment Program “Approved but Unfunded #32 - Institute for Dieticians Renewing © , While these projects seemed to have developed to solve rather specific problems in the allied health and continuing education areas, the reviewers believed there appeared to be an increasing need at the regional level for Committees or Task Forces in continuing education and allied health. During the second and third operational year, the KRMP began the build-up of the subregional offices. Kansas has nine subregions which correspond geographically to CHP regions. Great Bend and Wichita were the first two to be staffed. Topeka, Colby and Emporia followed in 1969. Full subregional staffing was completed in 1970 with the addition of Garden City, Salina, Kansas City and Chanute (see attached map). Kansas RMP ~7- . RM 00002 5/71 @ A site visit was held January 1969 to learn more about the regionalization process, the relationship of projects to the regional plan and to gain more {information about the decision-making and priority-setting process. The team reported that: 1) significant progress had been made in subregionaliz- ation, although there was not general agreement in the Region as to what the concept would be; 2) as far as the team could determine, the projects fitted into a regional plan; 3) objectives were very general and not measur-~ able and it was difficult to determine that priorities had been established. In February 1969, Dr. Robert Brown, Director of the Great Bend project, succeeded Dr. Lewis as Coordinator, With Dr. Lewis' resignation, the hypertension earmark project, #19, which he directed, was discontinued. Projects submitted and reviewed since May 1969 include the following: #33 - Nursing in Long Term Illness Disapproved #34 - Basic Continuing Education Program in . Community Health Nursing Returned for Revision #35 - Basic Education Program for Medical Clerks in Kansas Hospitals Returned for Revision #36 - Short Course in Instrumentation for Medical Technologists Returned for Revision #37 - Care of Patients with Fluid Electrolyte and Renal Problems Funded #38 - Revision of Project #35 Funded #39 - Demonstration Project to Improve Community Chronic Illness Care Return for Revision #40 - Comprehensive Nephrology Training ' Program Deferred #41 - Cancer Information Service Approved but Unfunde #42 - Cancer Care Continuing Education Program Oo , Approved but Unfunded #43 - Model Rehabilitation Project Funded by Rebudgeting #44 - Nurse Clinician Program Approved but Unfunded The approved but unfunded projects are included in the Triennial Application for further funding consideration. In these later applications the Region's program emphasis continued to be continuing education and its program implementation to reflect a one-by-one approach to education and training. In addition, nursing input in the development of curriculum or in project evaluation in nurse training projects was lacking, as was evidence of coordination between various professions involved in a single project. At the review of the last continuation - application in July 1970, staff raised the following issues: 1. The difficulty in determining the RAG's contribution in policy- making and goal setting; 2. The need for measuring the impact the projects make in the institution and health care patterns, as well as for more overall program evaluation; i Kansas RMP -8- RM 00002 5/71 3, The need for a regional strategy in allied health and continuing education; and 4, The need for greater core staff assistance from the central and subregional levels to the projects in such areas as formulating education design. Organizational Structure and Processes The Kansas RMP has a 20-member Regional Advisory Group, which includes five - consumer representatives. The RAG sets priorities, reviews ongoing operations, core staff activities and the activities of the Committees, Boards and o subregional councils. The RAG is served by the following committees: Executive Committee Continuing Education Unit Policy Board Lead Committee on Cardiovascular Disease and Rehabilitation Lead Committee on Cancer Renal Dialysis Medical Advisory Committee Renal Dialysis Advisory Council RAG Committee on the Annual Report The specialized committees listed above exist to study problems and offer technical advice on policy in their respective area of expertise. They do not participate in the review process. - In addition to these groups, there are nine Local Advisory Groups, whose membership is representative of consumers and most of the health interests in each of the subregions. They serve in an advisory capacity to the , Coordinator on matters concerning the health needs, problems and priorities and review project applications submitted from their subregion. The present review process provides for an assessment by core, the sub- regional advisory groups and the RAG. Although review by ad hoc. technical groups is shown in the review process proposed in November 1970, the Coordinator has stated that these are not yet operational. A schematic of the proposed review process is attached to the summary. ‘REGIONAL OBJECTIVES The Kansas RMP has developed the following overall goals for 1971: 1. To strengthen existing cooperative arrangements to improve health care and to establish new ones. 2. To improve health professional performance and thereby patient care through effective continuing education . , 3. To study and modify favorably the factors which influence distribution of health professionals and service. Kansas RMP -9~ RM 00002 5/71 4. To provide special training opportunities for new or relatively underdeveloped health professionals. 5. To evaluate components of the health care system and to support elements which rationally might increase quality, capacity or accessibility. 6. To improve communications, facilities, equipment and techniques related to the use of these. 7. To improve effects of the program in the Region. The Kansas RMP states that it exists to improve the quality and availability of health services to people within the Region. Functioning within the framework of regional cooperative arrangements, the program has designed planning and operational components which "create an environment favorable for recruitment of critical health professions and assure these professionals career satisfaction and prominence in their locations" in each subregion. DEVELOPMENTAL COMPONENT First Year Second Year Third Year $163,360 $201,134 $234,628 Deve lopmental activities described in the application are largely extensions | of ongoing Core activities and are generally related to the Region's seven — objectives. More specifically, the Region plans for use of the developmental component funds include the following: Data Requirements - For the past three years, KRMP has been co- sponsoring and jointly funding with CHP a study. to provide a broad data base for planning purposes, and the Health Manpower Information. Further development is plannéd for cooperative studies relating to health manpower, personal health services, and facilities. Manpower Training and Continuing Education - the Region has established working arrangements with both UKMS and the Wichita State University College of Health Related Professions (CHRP). a. Regarding the first, emphasis has been placed on the development of affiliated health education and. resource centers as part of regionalization efforts. Developmental activities, involving a potentially large number of medical communities seeking affiliation, will consist of extensive planning, initiation of education programs, communications support systems, and related activities. - Kansas RMP -10- . RM 00002 5/71 b. The working relationship with WSU will concentrate on development of an expanded role for the CHRP in planning and implementing education programs which are coordinated, multi-institutional, formal and continuing education programs for. health-related professions, and in analysis of present projected curricula. c, Closely associated with the WSU effort, the Kansas Hospital . Association and KRMP are cooperating in the development of ’ a. Personnel Development Program involving "inservice" ' programmed education in Kansas Hospitals for related health professionals, pre-professionals and other hospital personnel. Community Programs - Two community-oriented activities of the KUMC Department of Human Ecology are of particular developmental interest to the Region: "a. A KRMP proposal to assist in defining a health care plan ‘for the immediate area to improve accessibility. bp, A medical student preceptorship program to facilitate movement of students between institutions. , Four-level System of Medical Care - In June 1970, the Kansas Medical Society passed a resolution proposing a special study and recommending _ approval in principle of a four-level system of medical care suggested ‘by the editor of the Salina Journal, Salina, Kansas, at the 1969 State Medical Meeting. The system would consist of: 1) routine, immediate care in small towns by "superior nurses," operating under the direction of a physician; 2) physicians practicing in larger towns jn cooperation with nurses. in small.towns, and skilled nursing homes; 3) physicians (including specialists) in regional centers with fully equipped hospitals, laboratories and nursing homes; and 4) a broad range of | facilities and specialists as at Wichita and KUMC, interlocked with with State institutions and the Research center. - The Region views the study of such a four-level system as providing many areas for mutually usefull activities by KMS and KRMP which could be funded through a developmental componet. Administrative Procedures for Allocating Developmental Component Funds Contracts will be executed on approval of the entire RAG, and expenditures anproved by the Director or his designee. PRESENT APPLICATION Requested . Fifth Year . Core . $1,171,410 During the vast year, the core function has been reorganized to consolidate ace wea Led en teanefor came af the subrecional offices from projects Kansas RMP -11 RM 00002 5/71 to core. It now has six central sections and nine subregional offices. The central core offices, coordinated by the Office of the Director, include to following: 1. Office for Institutions and Administration - provides liaison between the central staff and nine subregions and develops working relationships with the Kansas Hospital Association and health-related institutions. 2. Office of Continuing Education - provides assistance in planning continuing education policies and strategy, in cooperation with the Continuing Education Planning Committee and Continuing Education Policy Board. 3, Office of Nursing - stimulates educational programs for nurses, both at the local and university level. 4. Office for Related Health Professions - develops at the regional leve pilot activities, feasibility. studies and educational pro rans and at the subregional level assists in developing projects an locally planned educational activities in the related health professions. 5, Office of Research and Evaluation -. develops models of evaluation for project directors and a planning and evaluation strategy to permit program assessment. The Office of Health Manpower Information Program, with responsibility for data collection and analyses, is also included in this Evaluation section. 6. Office of Special Services - provide data processing and communications services for the Region. There are subregional offices located in these nine locations - Kandas City, Emporia, Wichita, Great Bend, Topeka, Chanute, Colby, Garden City and Salina. ‘Geographically KRMP's subregions relate closely to CHP subregions. Several of these core functions were formerly funded as projects and have been brought into Core auspices during the past year. The personnel in the subregional offices work with both the planning and operational activities and serve as executive secretaries to the Local Advisory Groups. Core staff has sponsored a number of feasibility studies and joint planning efforts with other agencies. Examples of these cooperative efforts include studir conducted withthe Wichita State University College of Health Related Professions, with the Kansas Hospital Association, and with CHP. A complete listing occurs between pages 98-127. ; There are 66 (61 full-time equivalents) positions budgeted for 1971-72; ail but one are filled. ‘This number includes 38 professionals and 28 secretarial positions. Sixth Year Seventh Year xt 2 $1,350, 881 $1,620,083 Kansas RMP -12- RM 00002 5/71 Continuation Projects Continuation support is requested for the following two projects: Requested Project #4 - Cardiovascular Nurse Training $136,441 Support is requested to continue a unified in-service training program for nurses in providing care to acute cardiac patients in coronary and intensive care units. The program has trained over 100 nurses to date | in six-week courses on electrocardiography, cardiopulmonary resuscitation and a pharmacology of cardiac drugs. A physicians’ course will be offered in the spring of 1971, both to update physician knowledge and to overcome the ' problem of lack of confidence in KRMP-trainied coronary care nurses. 8 The Region ranks this project tenth. It is directed towards goal 2 (improving professional performance). Requested Project #38 - Bagic Continuing Education for Medical Record $6,415 Clerks. Funding would support a 3-month continuation period to allow extension of consultative visits beyond the present funding period for this project. Purpose of the project is to present a basic training program in medical record science to personnel in statewide hospitals who lack, or are unable to have, more formal training. Consultative visits © are designed to evaluate on-the-job performance of librarians after training. Forty-two trainees participated in the first session, with post-test scores indicating a 42% knowledge increase. Second and third sessions were scheduled for January and April 1971, with similar objectives and format. The Region ranks this project #12, It is directed toward goal 2 (improvement of performance). Renewal Projects The Region requests additional years of support for these six projects: Requested Project #1R - Great Bend Educational Program - $139,574 Site visit, Committee and Council action are required to extend support of this project for two additional years. The project which has been operationa] since 1967 requests support to continue | development of this comprehensive, subregional, mode] education center affiliated with the University of Kansas Medical Center. The Center provides physician education, nurse retraining and allied health continuing education. Proposed activities will continue with some change in emphasis, including a shift toward incorporation of linkages within the subregion and evaluation of the overall program in cooperation with the resources of the central Core staff. This project ia ranked first by KRMP since it addresses all seven of the Region's revised goals. It hag resulted in a contract between Kansas University and central Kansas medical centers and working arrangements among Kansas RMP -13- RM 00002 5/71 a variety of subregional institutions to carry out cooperative arrangements ; improved technological and related health professional support for physicians; reduced previous restraints to shared practice; improved recruitment of physicians to the central Kansas area; and reactivated many nurses through the reorientation course. The project has, through reassessment of delivery methods, increased both capacity --- with the development of home health care services ~-- and quality of care through initiation of improved programs of care. There has also been installation of communications, teaching and computer aids. Finally, the project allows for experimentation and evaluation of its activities. Sixth Year Seventh Year $110,446 $117,015 Requested Project #8R - Continuing Education for Cardiac Care - Wichita $39,526. Funds will continue the support of a unified training course for nurses providing care of acute cardiac patients in coronary and intensive care units, and to provide continuing education for physicians. To date, 265 nurses have completed the two-week's training, and more than 100 physicians have participated in the two continuing education courses. The Region ranks this project #11. It is directed towards goals 2 and 1 (improving professional performance and strengthening cooperative arrangements ). Requested Project #9R - Metropolitan Kansas City Nurse Retraining $32,074 (Reorientation to Clinical Nursing Project) Support is requested to continue an interregional program of retraining or updating nurses for reactivation in the Metropolitan Kansas City area. To date, 133 have been trained. Of the first 84 participants, 747, were working 12 months after course attendance. The 17 participating hospitals have indicated interest in continuing the program and capability for assuming responsibility after July 1, 1971. The Region ranks this project #9. It has provided spin-off in the form of instruction to teachers in outlying communities. The project is directed towards goals 2, 3 and 1 (improving performance, modification of factors influencing distribution of professionals, and strengthening of cooperative arrangements ). Requested Project #21R - Cerebrovascular and Neurological Nurse Training 535, 325 Funds will continue support of a program providing intensive training to prepare clinical nurse specialists in the area of cerebrovascular and neurological disease and trauma, and provide other short-term training for upgrading nursing competencies. Six enrollees have been trained to date to expand response and enrollment. The proponents wish to shorten the clinician course from 4 to 3 months, provide a variety of related courses varying in length and objectives, target the project towards other health — professionals, and publicize the program to reach a larger audience. The spring and summer of 1971 would be used to plan retargeting of the program to reach nurses in all of the mid-continent states. The Recion ranks this project #14, Kansas RMP -14- RM 00002 5/71 Requested , Third Year Project #23R-Kansas Medical Library System 61,68 Similar action is required for this three-year request. Future support is asked to continue development of this system . of medical library service designed to provide ready accessibility to health professionals. Additional activities proposed include: education of library personnel with limited experience, initiation of quality control of library services, completion of the revision of KUMC film catalog, publication and distribution of 1,000 medical bibliographies to medical librarians statewide, and the securing of future financial and administrative support for the library system in view of eventual KRMP funding termination. This project is ranked third by the region, relating to goals 1,2, and 6 (strengthening coop- erative arrangements, improving performance. and improving communications). Fourth Year: $68, 846 Fifth Year: $80,596 . Requested Project #32R-Institute for Dieticians. $12,000 Support is requested to continue this two-part training program, sponsored by the Kansas State University, which is designed to update knowledge of therapeutic dieticians currently employed and reorient inactive dieticians; The program offers a one-week institute in therapeutic nutrition and a second one-week institute in Dietary Department Management. The summer 1970 session trained 21 in the first course and 17 in the second. Both will be offered again in 1971 with no basic changes in format or methodology. The Region ranks this project #13. It is directed towards goal 2 (improvement of performance). - Approved but Unfunded Projects Projects. #40 - 44 were previously reviewed by Council in November 1970, No action was taken on Project #40 until the Council had an opportunity to review the Kansas RMP Anniversary Review application and site visit findings. Projects #41, 42, and 44 were approved, ‘but due to national funding constraints could not be funded. Committee and Council action on these three is needed in determining a funding level for the next year and not for approval of the activities. Project #40 - Development of a Comprehensive Nephrology Program Requested First Year $133,678 ‘Action on this project was deferred to a later Council so that the spite visitors could ceview the proposal in light of the total KRMP Kansas RMP . -15 RM 00002 5/71 program and statewide efforts in kidney disease. The Region has just terminated a renal disease training program, Project #37, Care of Patients with Fluid, Electrolyte and Renal Problems. The Region is presently negotiating with the Missouri and Bi-State RMP's to develop a multi- regional renal program appropriate for 910 funding (p.166) for sub- mission March 1, 1971. This project, #40, would be implemented in three phases. In the first phase, a six-week training course in center-based (or back- up unit) dialysis for community hospital nurses and technicians will be developed and implemented, and a series of courses for physicians will be developed to update knowledge of renal care and improve inter- action of physicians and nurse nephrologists. Existing KUMC facilities will be expanded for all training. In the second phase, physician | training will be implemented and training of Nurse Nephrologists begun. Hospital administrators will also begin training in both funding of treatment and accounting procedures. In the third phase, with planning already completed for coordinated renal prevention, detection and treatment, Nurse Nephrologists will be introduced into the care system. Future sponsorship for the project will also be arranged at this time. This project is ranked seventh by the region, and is directed toward goals 4, 3 and 2 (training of new and underdeveloped health professionals, modification of factors influencing distribution of health professionals, and improvement of professional performance). Second Year: $108,081 Third Year: $114,746 Requested Project #41 - Cancer Information Service $82,803 This project would establish a uniform and complete computerized central cancer registry to replace costly manual systems now supported by only a few hospitals in the State. Support of par- ticipating hospital registries will require education of medical records personnel and periodic auditing of abstracts in the hospitals by a traveling medical record librarian or expert cancer registry secretary. Other activities will include: provision of cancer con- | sultation service, study of the value of a newsletter in disseminating information on available registry data, education and computer-aided instruction, study of the value of a central registry and a tissue section repository, and a pilot study on means of extending cancer education in Kansas. The Region ranks this project fourth. It is directed towatds goals 1, 2,. and 6 (strengthening cooperative arrangements, improvement of professional performance, and improvement of communications facilities, — equipment and related techniques). Second Year: $88,358 . Third Year: $101,314 ..rigags RMP -Lo- NL VUUVe sre Requested Project #42 ~ Cancer Care Continuing Education Program $64,262 The purpose of this project is to train RN's, LPN's operating room technicians, and families of cancer victims in the etiology, diagnosis, and treatment of cancer; and to develop a coor- dinated hospital and home care program to serve the subregion. Evalua- tion procedures will be designed to record both knowledge and attitude changes in trainees and development of the hospital home care program. This project is ranked eighth by the Region, and is directed towards goals 2 and 1 (improving professional performance and strengthening cooperative arrangements). Second Year: $70,957 ' Third Year: $72,172 A —_ —————:” oy Requested Project #44 - Nurse Clinician Program "$125,212 The purpose of this project is to train nurses to act in a primary therapist's role in the medical management of patients, as a remedy to physician shortage and maldistribution, and lack of accessible, comprehensive services. The two-part program would consist of an eight-week core program and a six to ten month preceptorship program. The core program is designed to train a maximum of 120 clinicians after three years, with four classes per year. Each trainee -must have physician or agency sponsorship with a guarantee of employ- ment after training. Upon completion of the core program trainees will begin a preceptor- ship to develop in-depth knowledge and expertise in management of care under a physician's tutelage, and in a variety of possible prac- tice settings. It is viewed as potentially providing a comparison study with programs elsewhere in the nation geared to developing physician assistants. The project is directed towards goals 4, 3, and 1 (training new or underdeveloped health professionals, modification of factors influencing distribution of professionals, and strengthening cooperative arrangements). , Second Year: $122,183 Third Year: $126,155 Supplemental Project. : Requested Project #45 - Model City Health Manpower Education and $37,290 Recruitment Program. The purpose of this project is to raise the level of knowledge and understanding among Kansas City, Kansag model neighborhood residents about good health practices and to provide a means of their entry into health professions as health aides, while at the same time easing the health manpower shortage and access problems prevalent in the area. Under supervision of a health coordinator, six health aides will be involved in class- room instruction on community health, practicum activities, and supervised activities involving communication with and teaching of residents in Kansas RMP - 17 - RM 00002 5/71 need of education or services, A Model Cities supplemental grant will provide the trainees’ salaries. Another Model Cities project is being funded by Missouri RMP in the Wayne-Miner area of Kansas City, Missouri. The Region ranks this project sixth. It is directed towards goals 3 and 4 (modification of factors influencing distribution of profes- sionals and training of new professionals). Second Year: $37,290 Third Year: $37,290 Terminated Projects (6/71) Project #24- Food Service Personnel Using Dietary Consultant Approach Project #37- Care of Patients with Fluid, Electrolyte and Renal Problems GRB/2-17-71 Wa KANSAS REGIONAL MEDICAL PROGRAM SUBREGIONS (AND DATES ACTIVITIES VERE. INITIATED) iS Win ITN I Northeast - II Southeast III. Southcentrai IY Flint Hills VII Northwest - yO Y Central VIII Northcentral x VI : Southwest oe IX Capitol: " 8 prams ~ . u re , 8 S CHEYENNE 1 AAWLIN ay ware ITT Sao Se Te curs . ) Oi $ \ ‘ | _s jorearen Norton” UU pPatuirs [sity “| ESE nL nePUSUIG | [ WASHINGTON, }IEANSHALL ynewans i "| jt ° i i : : 5 (OONIPRAN @ & } : é ( i | t ka b o | \ i : re | Loe? i ’ ; § a ; : : { Tt jarenison 7 Fi 1 SHERMAN THOE, - f so pOLCUD 7 os RATE 8 t HOMAS j SMERIOAR ORANAM }ROOKS Fossoane — j. farvengcn “{ t per AILEY fPOTTAVATES JACKSON | { ; XA i : ' : “4 6 —, | eS ; 1 i ‘ ta ‘ | yerrens, ; OD if efile ‘| 4 . | Ad i | | ) eave ; i ¢ y be < i ; { 4 9 amernemnameremvine, * ' t ORTH ° veratt: it 4 ; 4 ii _kormwa tt. | tt een a ik ct j { t ONCOL ——"Tj Co rt | Safvansas WALLACE (la TC6 - : mem eons sd ! ij . | LOG. NA? F OVE {iniGo ‘euus YROSSELC ’ Sexson L te fuans AINSE. “3/1/0 “, Le aN Cs $ . { H r prary {ACRES |: 5 ONSEN, | ty | eaves i (_ PEE eee RN SLED } { 4 hays i t oe ain i , \ monais| 77 OSASE {ie 1 j 4 f Me (CHP) is \ CEUUStFOATH 10/5/70 i } (eoRaTS| pA ae a nee remem ° execear—; MACE enn | aSalina bi. ae : EOLEY (wicnita jscorr {tang NESS \ an (aaata : Plot ; } RY 7 NES | (Re So | — o fEmporia ati \ ‘ i 4 52 o™~, , f OVENSO HARIGN j f L/Ve ~ \ i fo "3 4d . + } eae: cee poe he een j i ey AiGreat \ imce Be pot ey CHASE 4[ — | i RiSend oF . i] \eorrer [ GROERSOR /UNN } i ‘ dE “| “4 | “ : |. granee — \8/15/677_| LA ie ay i mRMTON TREARNY Pricey HODGEMAN ts | yiaerGnO | — 4 i r : : ' 7e L478 { ; {RENO ane, HAAVEY —— a \_. i ihe : 3 ti UBUTLER raretao03 fers RCLEN ;D0vROON f i \ City ae 5 i leowaios 4 ya “ t ; i j Sm wel " FFORD Lt i : i .. es coswick jf 5/1/67 t bor fe : \- 4 atm Yee - ss th I ‘ : eae i i . ; ! PLE PRATT werent eh. | sczen ee see carro i STARTON {GAANT HASKELL | OWS t | qaNeHaN oh ry 17%, ° 2 is ke i j } 4 bo i \ \ ( es 5 eee “4 24/4/76 t i { : (4 ; td ; ‘ 7 ELK \ | h * k PY | pO rn Pe fe chanutgs ‘ i j [nape ECLARK ra poeancen asa COMLEY {. i: “s Gut Ane SS ORERER ce, MOHTCN 7 STEVENS fF SCWARD 4 “ iComaANGHe AERPEN ; , lmrren. ren St pseweno f [ORAS 1! * i _ feaarauaey, \° oT re meee 5 i. 3 4 8 | a et ; ta ; R ; 4 { | 4 i : i i . TZ/S 20000 WH ~~ _ ’ | --+ Docuuant flew when requircd 5 : ne te view of project chnical aspacts ‘A Decision to. continue review process project to DRM? Decision to fund project , ” : nh : nm ‘ Oc x KRMP PROJECT REVIEW PROCESS g _ Estimated . ° -. Days 1 KRMO CHP Technical Advisory Personnel & to -KRMP | Medical: - pave ‘~* ' Complete Exec. Conn. | Lead A 8 or Educa-i Techno- ! Evalua- | Grants , . Stege .. | Proponents . Staff i RAG LAG Gomm's. | ROHEW } Agency! Agency !Health tion § logical tion Review ob Di etl | 4 “oo! a no fo LAS c ! wily JAS - . | ‘ : ‘$9 . . | aan = FS ~~ 236 HL AT 7 65 Ia T G ) 3 --bo 1 o- ce De na —_— a2 ot S -eeeee . 2 et er e 90° * ° \ 100 120.- ——— : , 130 re a 7 _ . eh pS . KEY" - = Docunent flow (W) Review of preject need , G&) Information _ Decision to submit -20- DEPARTMENT OF HEALTH, DIOQUCATION, AND WELFARE PULRLIC HEALTH SERVICE HEALTH SERVICES ANDO MENTAL HEALTH AOMINISTRATION Date: February 16, 1971 Reply to Aétn of: Staff Review of the Triennial Application from the Kansas Regional Subject: Hedical Program RM 2-05 To: Acting Director ’ Regional Medical Programs Servicé ij]. {HROUSH: Chairaan of the Month /),7),/ > . LYN het i Chief, Grants Review -Sran ngs ay t/ Chiei, Grants Management Branch al CN fi can al Davelopuent Brogch" wetsinnen ~ % Acting Chief, Reg Staff met to review the triennial application subuitted by the Kansas Regior Medical Program, A primary purpose of thes review was to identify and dise issues for the site visit on Narch 4-5, Since only two projects have come mitments and this is a triennial look, deliberation of the continuation portion of the application seened superfluous. nal uss The application requested the following total costs for the 05 year! Core $1,496,641 Continuation Projects ov 503 $4 and #38 Renewal Projects 499,746 #s 1, 8, 9, 21, 23, 32 Previously Approved/Unafunded 471,037 #s 40, 41, 42, 44 Hew Projects (745) 37,290 Developacatal Cemponent 163,350 TOTAL $2,750,577 Since Kansag was one of the first Regions to use the nev appLlicat: staff began the discussion with some comacnts about some of the i and problems the forms presented and about how Kansas had used them. l. Staff agreed that the forms presented good coucice descriptions of core feasibility studies and projects and that this facilitated use of the descriptor forms for the HIS system. Oa the other hand, the brevity of the material on projects made it difficult to dotermine wiethex progresn was occuring as planned, the accepty ‘nee of the activity, its spinoff effects, the difference it was makings in chongiag the deli wag doing what, and tho methods used to curry ont the activity. 2. Waties the local review process has the reaponsibiiity for nosuring adequate revieyv of nnewocs to these questions, staff could net judeon the adequacy of the reviaw process by the yes/no enavers to fora 13 and they vere further disturbed by the cdutosion of the Coordiaator thot Kansas had ne peor technical review -21- ~Qe the Region would discuss their overall stratcsy in major program areas, such as Continuing education. In the Kansas prograa by far the largest number of projects and amount of money are invested in continuing education. In the past, fragmentation of thes activities has givea cause for concern about a coordinated plan in this arca, In this application, the sense of fragnentation is furthered by the forms’ picceneal approach to the program through the discussions in terns of relationships with organizations, projects and core feasibllity studies, rather than as a whole. As a consequcnce, staff saw the need for information of this sort being cither requested in the application or in an interim position paper which could be made available for the site visitors and other reviewers, 4, There is no overall budget picture giving totals for the 02 and 03 years and subtotals for core and projects for all years, Becrsuse the progran had to be written to provide this information the MIS could not have the. information available until the time of the meeting. Staff, therefore, did not have it available for earlier individual study aa thus had to duplicate the systea's efforts in order to lock at the fiscal side of. the Region's request.prior to the meeting. Indirect cost figures are not available for the 02 and 03 years for budget projection purposes. 5. Since no geographic or denographic data was provided, staff needed to call the Region to get the information. Thus, while Kansas has made fairly good use of the forms, it involves a special challenge to staff in providing additional material for the site visitors which will highlight the issues and present a clearer: picture of the Kansas progren. fhe following issucs and questions for the site visitors and national revicvers have been grouped according to the categories of the Program Review Criteria. 1. Goals, Objectives and Prioxities Kansas has outlined seven objectives and given each project a priority ranking purportedly based on its relation to the objectives. What is the extent of the acceptance of these objectives and the priority ranking on the part of those associated with KRUP-Core Staff, Local Advisory Comnittees, RAG, The Great Bend program is ranked 1 and Dr. Brown was the director of this program before he became Coordinator, 2. Organizational Effectiveness a. Coordinator - Dr. Brown, who is well-known throughout the state, is generally regarded as a strong coordinator. ‘there are some indications fron core staff meabors that Dr, Brova's span of control in the wvoole progzann may be too restrictive. As an exanple, RNUuPS Staff. has learned confidentially that his staf£ are not permitted to attend RAG meetings. b. Core Staff - What is the relationship between the central core staf£ in Kansas City and the subregional staff? What kind of assistance docs - the central core provide the subregional coordinators? With regard to core ~— -22- ~je eabibility studies: 1) Way is KRMP supporting activities desisned directly for medical students and residents? 2) Vhat is the need for three automated medical record systems (p. 110, 111, 117) and what is the relationship among the three? What use is KIMP making of the large amount of ongoing work in this crea? c. omitted - section in outline not applicable to discussion. d. Regional Advisory Group - To want extent is this group a creature of the Coordinator's or an independent ageat? ‘here is one nurse, who is affiliated with the University and no allied health representative on the RAG, In view of the large proportion of activities involving these groups, should consideration be given to increasing this representation? Is there sufficient minority group (blacks, Indians, migrants) representation? What provision is being made for VA representation? Where is there provision for local Advisory Groups" input into the RAG's decision naking? e. Subresionslization - Kansas Rie has nine subrepional offices, two of which will be visited by the site visit team (Great Bond and Wichita). Concerns which staff brought up for consideration are: 1) provider and consuner acceptance of the subregional programs; 2) accomplishnents, any changes in direction and future plans; 3) functioning of the local advisory roups; 4) the relationship between subregional core staff and projects either ongoing or proposed) in the subregions; and 5) linkages with the medical school and other health institutions; 6) spinoff effects in terms of serving as the impetts for the establishment of similar activities in. the surrounding area; 7) how do the other subregions view the Great Rend and Wichita progrems; and 8) what is the decisionemaking process for deciding whether a project vill be designed for a subregion or the entire Region? 9) in a subregional project, who agrees that a particular hospital serves as a focal point for the project? With regard to the progran at Great Bead in particular, staff vondered: 1) Is there any educator input in the design of the educational program 2) lias the progran actually resulted in the recruitment of additional health personnel to the area; 3) What is the participation of the LAG's in goal setting? aS5 In reviewing the Wichita program, staff queried: 1) What is the relationship of the subregional office to project #8, Continuing Education for Cardinc Care at Vesley Mospital, and what assistance, if any, hus beon offered to the proposers; 2) Vaat is the relationship with the CUP(b) agency in Wichita and the Wichita State University College of Health Related Professions; 3) Mow had the PUP efforts there dealt with the carly secessionist moves on the part of physicians and hospitals? 3. Involvenent_of Resional Resourcos = She KEMP began as a medical school dominated progres, ‘fae pxecent coordinator has taken several steps o change this, such as replacing most of the vacancies which eccurred on core staff after the last Coordinator left with noneuniversity faculty -23- hn L : : : : pexsonnel and increasing the subregional aspect of the progren. How effective have these efforts been, staff wondered, With the appointment or a new CHP(A) Agency Director, what is the relationship with this agency. 4, Assessment of Heeds, Probleas end Resoumees - Nany references are made in the application ‘to the collection of data, including a Health Manpower Information Program based in Topeka and the Health Information Systen funded by core, What have these studies and surveys shown about health care needs in Kansas and how has this information been used to determine objectives and goajs, as well as project activitics. Staff noted an apparent duplication of effort om core staff in collecting and analyzing data which should be investigoted (refer to appendices). 5. Proeran Implementation and Acconplichnents - What kinds of propozals are coming up through the review process and wnat kinds have been disapproved during the past year? Wahat kinds of activities would the developmental component fund? Way has the Region elected to renew so many projects? What efforts is the Region making to find other sources of support for these activities? As noted before, the Kansas program has a heavy continuing education caphasis. mat role docs the Continuing Education Committee vis a vis the Director of Continuing Education and core staff, Dr. Rising, play in determining this aspect of the program? In the past, there has been a unilateral, rather than a multiedisciplinary or teen approach to continuing education and training. Has the Region's approach to this changed? What is the role of Lead Committees in determining objectives and priorities in their respective areas of concern? 6. Evaluation - Staff was generally pleased with the Region's project evaluation. Objectives are set in measurable terms, progress is evaluated accordingly and projects appear to be monitored by core staff. Models of evaluation for project directors are also provided by the evaluation section on core staff. Staff believed, however, that progran evaluation needed to be strengthened. The following staff members attended the mecting: Dona louseal, Grants Review Branch Teresa Schoen, Planning & Evaluation Prank Zizlavsky, Regional Development Branch Gerald Gardell, Grants Management Branch Charlie Barnes, Grants lanagement Branch Lawrence Pullen, Grants Henagemant Brasich Julia Kuhla, Continuing Education Branch Bob Chambliss, Organizational Liaison -24- -5- Ted Moore, Kidney Disease Control Progrém Joe Ott, Systems Management Joanne O'Malley, Systems Management Harold O'Flaherty, Planning & Evaluation Spiro Moutsatsous, Planning & Evaluation Atv Q Nowe.’ Dona E. Houseal Fublic Health Advisor Grants Review Branch alte . (A Privileged Communication) * SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE KANSAS REGIONAL MEDICAL PROGRAM pm 00002 5/71 . FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: The Committee recommended that this application which requests: 1) the activation of four Council approved but unfunded activities, 2) renewed support for six activities, 3) the implementation of one new activity and 4) a developmental component, be partially supported as follows: COMMIT - DEVELOPMENTAL SUPPLEMENTAL YEAR MENT COMPONENT PROJECTS TOTAL 05 - $1,314,266 1/ 163,360 766,447 2 2,244,073 06 1,350,881 1/ 201,134 606,161 2 2,158,176 07 1,620,083 1/ 234,628 49,288 2/ 2,503,999 TOTAL $4,285,230 599,122 2,021,896 6,906, 248 SITE VISIT AND COMMITTEE RECOMMENDATIONS DEVELOPMENTAL . | TOTAL YEAR STAFF COMPONENT Al, COMPONENTS 05 Deferred to -0- | | 1,800,000 1&2/ 06 Site Visit -0- 1,800,000 1&2/ 07 Tear -0- 1,800,000 1&2/ TOTAL - 5,400,000 1/ Includes core and projects #4 and 38. 2/ Includes projects 1R, 8X, 9R, 21R, 23R, 32R, 40, 41, 42, 44, 45 Critique: In its deliberation, the’ Committee accepted the report of the , site visit to the Kansas Region on March 4-5, 1971. Under the dynamic leadership of the Coordinator, Dr. Brown, this Region has come far since its early operational years when University representatives dominated the RAG, its faculty occupied the major Core positions, and the projects were generated at the University, if not actually located there. The University's predominant influence has been gradually disengaged from the progran. In line with its growing commitment to the regionalization of health services and education, the University now looks to RMP as a KANSAS RMP ~2- RM 00002 5/71 vehicle for subregionalization of medical education and new models of health care delivery. Kansas has severe medical manpower problems throughout most of the state. Most of the KRMP's programs have been directed to some aspect of the manpower problem, usually continuing education for health professionals. While many projects continue to be continuing education - oriented, their emphasis has changed from that of an end in itself to a means of fostering better health care. The subregional part of the Kansas program, which > - includes. a local Advisory Group and a Core staff member in each of the - nine subregions, has been developed in order for people in these medical service areas to determine their own needs in improving health care. | Part of the site visit team went to Great Bend and Wichita to meet with Core staff members, project staff, and providers and consumers involved with KRMP in these communities. While early subregional efforts were developed to design models for the entire Region, the visitors reported to Committee that the Region seems to have learned from this. experience that each subregion must determine its own model. The léadership for this program lies clearly with the Coordinator, who is a forceful administrator, is respected throughout the state and has apparently a firm grasp on the Region's problems and the methods needed to solve them. He has been successful in building RMP committees around existing groups established by other agencies, rather than creating separate RMP groups. He has established a very capable Core staff whose members are involved with the new Wichita State University College of Health Related Professions, with migrant and inner city health problems, and in many subregions providing staffing for CHP areawide planning groups. As a consequence, RMP is becoming .an integral part of health services planning in Kansas. Decision-making, priority-setting and review processes are areas of weakness and should be strengthened. The review process could not be evaluated since it is still on paper. The policy-setting Lead Committees in various categorical areas are still just being organized. The RAG relies heavily on the Coordinator for direction of the Program and for setting goals, objectives and priorities. Because Dr. Brown serves as the principal conveyor of information between the RAG and Core staff, Local Advisory Groups, the Lead Committees and project proposers, the RAG is isolated and generally reacts to, rather than initiates program ideas. The communications problem attendant to Dr. Brown's key position of filterer of information has also prevented better LAG input into establishment of regional goals and objectives. Committee concurred with the team's recommendation that the Coordinator develop broader communications linkages among the various regional groups and place high priority on fostering a more independent role for the RAG. At the same time, however the Region shows potential for securing provider support and establishing an organizational pattern for the regionalization of improved health care delivery and health manpower education which Committee believes. is valuable and should be encouraged. _ KANSAS. RMP . (=3- | | RM 00002 5/71 Committee had concerns about the Region's priority-setting. and decision- making process, which ranked a computerized cancer registry proposal | (Project #41) higher than a Model Cities health aide training program (#45). The site visit team members present at Committee indicated that the hard decisions required in coping with a reduced budget might produce a different alignment of priorities and that with regard to the tumor registry proposal, the Coordinator would probably be able to take advantage of any funds available in the state for further developmental efforts. Committee, thought however, that their reservations about. the wisdom of allocating RMP funds for the proposal should be communicated to the Region, since the evaluation of existing funded computerized registries as related by. RMPS staff showed generally inadequate results. Committee suggested that the Region be reminded of Council policy on tumor registries, which states that RMP support may be provided when: they make important contributions to regionalized improvement of patient care, they plan to disengage RMP funds promptly, and RMP support is confined to organization, planning of output and development of new methods and not major equipment purchases or operation. Committee agreed with the rationale for the site visitors' funding recommendation which would give the Region some funds to continue the more successful ongoing activities and at the same time apply pressure to the Region to develop new and more innovative activities. Because of the RAG's relative inactivity in the decision-making and priority-setting process and the latitude for developmental activities provided for in the Core budget, there was no dissent with the site visitors negative recommendation on the developmental component request. Project #40 - Development of a Comprehensive Nephrology Training Program, was reviewed by the Ad Hoc Panel on Renal Disease. Committee did not have access to the Panel's recommendations during its review. The proposal had been reviewed in November 1970 and deferred until it could be looked at by a site visit team in terms of its relation to the overall program. While the site visitors did not assess the technical merit of the proposal, they questioned the proposers. about the proposals relationship with other programs in the state, the efforts of the RMP Lead Committee in Renal Disease and the proposed glo application to be submitted by the Kansas, Missouri and Bi~State RMP's. The team was satisfied that the Region would coordinate regional resources, seek to prevent duplication of effort and combine efforts for planning of a complete regional program. The site visitors included funds for the proposal at a reduced level in their overall recommendation for support. Committee accepted the recommendation. The Panel deferred their decision because of lack of information. ° Panel Technical Critigue: Because the Panel had been provided only a short summary of the proposal and not the complete description originally submitted in August 1970, they deferred their recommendation. _ In addition, they stated that the proposed short-term training (several _ days) for physicians has been proved inadequate for proper training. The home dialysis training is not discussed fully enough in terms of existing needs, present status of therapy and resources in details of design and method. , RMP/GRB : DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE .. : ‘ PUBLIC HEALTH SERVICE -- ‘ © : : HEALTH SERVICES AND MENTAL, HEALTH ADMINISTRATION Date: March 26, 1971 Reply to : Alin of: _ Subject: Kansas. Regional Medical Program Quick Site Visit Report, March 4-5, 1971 To: Director Regional Medical Programs Service THROUGH: Acting Deputy Director ‘Regional Medical Programs. Service _ I. STRUCTURE The site visit was divided into two parts for the March 4 session because of the importance of the subregional program and the need to speak to the Creat Bend and Wichita representatives in their home. communities. A list of the site visitors is attached. The site visit was structured so that: 1. The Kansas City team (Dr. Schmidt, Dr. Weinberg and Miss Houseal, : Miss Schoen and Mr. Maddox from staff) met with the Coordinator, ‘ the RAG, various’ Committee members and representatives of the University, CHP and others interested in RMP from around the state, and ‘2, The Great Bend-Wichita team (Mrs. Wyckoff and Dr. Nicholas, and Mr. Zizlavsky and Miss Kula from staff) met with Core staff members, project staff and providers and consumers involved with the KRMP in these locations. After spending the morning in Great Bend and the afternoon in Wichita, this team joined the first - group in Kansas City. The entire team met with Core staff on the second day. IT. MAJOR QUESTIONS Briefly, the major concerns of this site visit were: 1) the amount of control over the program exercised by. the Coordinator; 2) the representa~ tion and decision-making of the RAG; 3) KRMP's relationship with the University; 4) the adequacy of the technical aspect of the review process; 5) the apparent programmatic emphasis on continuing education; 6) the involvement at the subregional level and the relationship of subregional programs and groups with the regional groups and the statewide program; ‘and 7) the relationship of KRMP with statewide groups, such as CHP. Page 2 - Director, RMPS III. FINDINGS AND RECOMMENDATIONS Dr. Brown, the Coordinator, is clearly the pivotal point in the Kansas program at present. He dominates the Core staff, and, the Regional Advisory Group is his creature. He serves as a filter for communications between the RAG and Core staff, Local Advisory Groups, categorical Lead Committees and project proposers. As a consequence, the RAG is isolated and fairly weak and generally reacts to, rather than initiates, program ideas. This amount of ¢ontrol can be rationalized somewhat by Dr. Brown's need both to shore up the program after the last Coordinator resigned and to disengage the program from the medical school's domination. While Dr. Brown's control of the program may be justly criticized, he has, however, several major accomplishments to his credit.. He has assembled -a very capable Core staff. He has the cooperation of the appropriate state- wide groups and has been even more effective in working with individual physicians and hospital administrators in getting things done. As in. many Regions, RMP has been on the scene longer than CHP and has consequently been more successful in garnering support at the local level. Dr. Brown has also been very adept in building RMP technical committees around existing groups established by other agencies, rather than creating separate RMP groups. Examples of such efforts are the Pulmonary, Renal and Cancer Lead Committees. -The Coordinator also seems to be directing increasing attention to health services delivery, and there is evidence that he is in contact with those in the Region who may be developing health maintenance organizations. The site visitors commended Dr. Brown for taking advantage of these kinds of opportunities, but they also recommended that he involve the RAG and other regional groups in more of the decision-making so that the program would be less of a one-man show. The technical aspect of the review process is still on paper, but is expected to go operational this year. Provisions have been made for CHP comment. In Great Bend, the multi-faceted education program for health care person- “nel is making progress. Particularly impressive is the. R.N.. retraining program, which returned 55 nurses to active employment out of a total “enroliment of 65 in the course. While the Great Bend project has not been ' able to recruit more physicians to the area, it has helped those practicing in the Great Bend area by arranging for individual consultation on difficult cases by K.U. medical center personnel. Leadership. in the Great ‘Bend area is distributed among the director of the Great Bend project, the subregional Core staff and the Local Action Group, comprised of multi-agency and professional representatives; as well as consumers. The LAG has been Fos Page 3 - Director, RMPS particularly active in helping to identify and involve local people in the RMP sponsored educational activities. The subregional Coordinator in Wichita has developed excellent working relationships with local project directors and with health professionals in surrounding counties. He has brought about stronger ties with the State Medical Society and has been instrumental in achieving better relationships between. physicians and hospital groups. ' He has also been a prime instigator in the.establishment of the new College of Health Related. Professions at Wichita State University. A weakness of the Wichita Core operation was the data collection efforts, which so far have not provided information which is applicable or helpful to RMP planning. The Wichita subregion also has a mature and functioning LAG, which relates well with the CHP (b) Council. ‘LAG representatives from both subregions indicated that while they have informal. communications with the RAG through Core staff and, in one instance from a RAG member who also is on the LAG, some better method of formal reporting of RAG meetings, such as written reports of ‘RAG meetings, and of getting LAG input into establishment of regional goals to be instituted. After discussing their experiences in Great Bend, Wichita and Kansas City, the site visitors realized that the continuing education and subregional activities, rather than being ends in themselves, had been developed to regionalize health services for improved health care on the local scene. “Core staff and Local Advisory Groups were developed in order for people in these medical’ service subregions to determine themselves what they needed. One of the biggest lessons -the Region seems to have learned from the Great Bend and Wichita experiences was that the model for each sub- region should be "what each subregion wants to do." In line with the subregional concept the University is now looking to RMP as the vehicle for subregionalization of medical education and new models of health care delivery rather than, as in the early days of the program, using» RMP as a funding source for continuing education programs out of ‘the medical center. In allied health, the RMP. will support and utilize the resources of the newly developing College of Health Related Professions at Wichita State College. The team concluded that the Region, has made significant progress since the ast site visit. They are developing a subregional program using ‘continuing education as a vehicle designed to improve health care. The most significant need is for the Coordinator to develop broader communica~ tions linkages among various regional groups (RAG, LAG, Lead Committees, etc.) and to foster a more independent role for the RAG. Page 4 - Director, _RMPS The funding level recommended for the Region's ‘fifth, sixth and seventh years is approximately $1.8 million (direct costs). Because ‘the RAG is not an active enough participant in the decision-making process, the developmental component request was disapproved. race &, Ae crac ut ye Dona E. Houseal Public Health Advisor Grants Review Branch , REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) MAINE 'S REGIONAL MEDICAL PROGRAM RM 00054 5/7] / Medical Care Development, Inc. April 1971 Review Committee 295 Water Street , Augusta, Maine 04330 Program Coordinator: Manu Chatterjee, M.D. This Region was awarded $904,473* for its 9? operational year ending September 197]. The 02 year award included indirect costs of $1,976, which represents an average indirect cost rate that does not even apnroach one percent. The current application requests one~year supplemental funding of $27,896 from the Model Cities earmark to conduct 8 program in Family Nurse Associate Training which wil] have an impact in the Model Cities areas of Portland and Lewiston, FUNDING HISTORY Planning Stage Grant Year Period Funded (Direct Costs) 0} 5/67 - 4/68 $193,909 02 5/68 -~ 4/69 358,170 Operational Program Funded Future Commitment Grant Year Period (Direct Costs) (Direct Costs) 01 7/68 - 6/69 $ 428,106 --- 02 7/69 - 9/70 (15 mos.) 1,229,634 | wee 03 10/70 - 9/71 904,473* --- 04 10/71 - 9/72 / +e- $637,642 05 10/72 - 9/73 --- | 57,233 * Reduced to $868,592 (see footnote on page 2) Maine RMP -2- "pM 00054 5/71 « Maine's Regional Medical Program received one of the first anniversary program site visits in October 1970, and was enthusiastically recommended for developmental component funding by the site team, Committee, and Council. Supplemental funding for two new projects was recommended as well, for a total 03 funding level of $1,304,969 for this Region. Financial stringencies, however, have prohibited the awarding of new . funds, and this Program is operating at its previously committed level of funding, as follows: Core ; $440,496 Guest Resident Program 30,940 Kennebec Valley Regional Health Agency 171,144 Smoking Control Program 37,538 Coronary Care Program “146,812 Physicians’ Continuing Education 56,228 Regional Library 21,315 $904,473* Regional Objectives Maine's Regional Medical Program and its Regional Advisory Group have isolated six program objectives. In priority order these are: 1).experiment with new methods for delivering health care to disadvantaged areas; _ 2) develop new health manpower; 3) improve and update the level of medical knowledge; 4) ‘develop subregional capabilities for area-wide health planning and the delivery of health services; 5) maximize the capability for delivery of quality medical care through community hospitals; and 6) maximize the capability for providing diagnosis, treatment, and medical educational leadership in referral hospitals. October 1970 Site Visit The prologue to the site visit report gives a good summation of the sentiments of the Committee, the site team, and the Council about this Region, The site visitors saw the evolution of Maine's Regional Medical Program as being remarkably consistent with that of the program at the national level - starting with a categorical emphasis but expanding to include a clear commitment to the development of an integrated system of medical care which provides access to medically depressed populations as well as improvement of availability of care to the cummunity at large. The six program objectives identified by the Region, and ranked in priority order by the RAG, reflect this emphasis, but also are geared to the * Because of RMPS fiscal stringencies, the amount of money available to Maine during its 03 year has been reduced to $868,592 Cincluding $50,693 carryover). Rebudgeting among program components, however, has not yet been completed. wee Maine RMP -3- RM 00054 5/71 » unique needs of Maine itself. The progress MRMP has made to date appears good, with some peaks of excellence and few valleys. Essentially, the Region has been carrying out the. public health functions of the state. The visitors were impressed with the sincerity and effectiveness of the Coordinator and his core staff. With the few exceptions described in the body of this report, the role of the Regional Advisory Group indicates the readiness of the Region to receive and administer developmental component monies. The Regional Advisory Group is established as the final review authority and comfortably occupies a policy and decision- making position. MRMP has developed good and productive relation- ships with other organizations in the state. In general, the site team thought this Region possessed the regional maturity, the capabilities, and the appropriate management abilities to make good use of developmental component monies. The site team did suggest, however, that the Region take steps to: 1) change the character of consumer representation on the RAG to include non-medically oriented consumers and those of modest means; 2) develop a subcommittee or task force structure for the Regional] Advisory Group; and 3) clearly separate the functions of. the Board of Directors from those of the Regional Advisory Group. O01 Year Request Project #20 - Family Nurse Associate Training Proposal $27,896 This proposal is related to the first two program priority areas of the Region: 1) experimenting with new methods for delivering health care to disadvantaged areas; and 2) developing new health manpower. The goals of the proposal are: 1. To increase the depth of skills, knowledge, and understanding of specially selected family-oriented nurses. 2. To provide more effective and comprehensive management of family patient care with physician direction in the home, the clinic, and other community settings. 3. To relieve the stress and pressure on existent systems and facilities delivering health care. The application states that this wil] complement an existing RMP-supported Pediatric Nurse Associate program and should be followed by an OB-NA program to complete the trilogy. Six Registered Nurses (four of whom will come from Model Cities areas) will participate in the first course. The year-long schedule includes four months of intensive training and eight months of field supervision. Six hospitals and agencies (including the Model Cities Neighborhood Health Station) have offered their facilities for use in the clinical portion of the program, Program evaluation will be the responsibility of MRMP's Division of Evalu- @ and will involve a pre/post/follow-up assessment. Maine RMP -4- RM.00054 5/71 4 The budget submitted to RMPS provides mainly. for personne] and consultant services. Other sources of support, to inc\jude student stipends, are being explored. If the first course is successful], two additional] years of support will be sought from RMPS. Efforts will te made to build this training program as an on-going course of the University of Maine's Continuing Education Division. © RMPS /GRB/3/12/71 “(A Privileged Communication) © _. SUMMARY OF REVIEW AND CONCLUSION 0 a APRIL 1971 REVIEW COMMITTEE MAINE'S REGIONAL MEDICAL PROGRAM RM 00054 5/71 , FOR CONSIDERATION BY MAY .1971 ADVISORY COUNCIL RECOMMENDATION: Additional funds be provided for this application. Year Request Committee Recommendation 03 $27,896 $27,896 CRETEQUE: The favorable reports of the October 1970 site team and the January/February 1971 Review Committee and Council regarding the accomplishments and future potential of Maine's Regional Medical Program were recalled by the reviewers of Project #20 - Family Nurse “Associate Training Proposal. It was agreed that this supplemental application for Model Cities earmarked funds was related to the Region! s first two priority areas: (1) experimenting with new methods _ for delivering health care to disadvantaged areas, and (2) developing new health manpower. The training of Family Nurse Associates was seen as -the second step in Maine's nurse associate triad: complementary ‘to existing RMP supported pediatric NA and future obstetrical NA programs. Dr. Manu Chatterjee was not present during the discussion of this appligation. GRB/RMPS 4/19/71 (A Privileged Communication) REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION MISSISSIPPI REGIONAL MEDICAL PROGRAM RM 00057 5/71 University of Mississippi Medical Center April 1971 Review Committee 2500 North State Street Jackson, Mississippi 39216 Program Coordinator: Theodore D. Lampton, M.D. This Region is currently funded at $1,095,428 (d.c.) for its second ; operational year ending June 30, 1971. $320,241 of this amount represents 4 unspent first-year funds reauthorized as carryover into the second year. The Region currently receives indirect costs of $375,958 which is 32% of the direct costs award. It submits an application that proposes: (1) Developmental component for one year. (2) The continuation of core and seven projects for one year. (3) Three years additional funding for one project, CPR Training. (4) Three-year funding for two new projects, in hypertension control and in renal diseases. The latter activity has been supported for an interim period through carryover funds. (5) One-year funding for Phase I of a new project in Stroke Rehabilitation. The Region requests $1,430,979 (direct costs) for its third operational year, $301,023 for continued funding of two new projects and one renewal project for the fourth year, and $301,189 for the fifth year. The breakétit chart identifying the components for each of the three years follows. The Region's triennial application is expected next year at this time, when a site visit is planned. The Region elected to request developmental funding and new project funds to take advantage of the planning ahead that has developed this year. The former coordinator has resigned to work full-time for the VA Hospital, but remains on the RAG. Dr. T.D. Lampton, who had been his associate, has been appointed as coordinator of the RMP. The former Dean of the University Medical Center, Dr. Robert Carter, also left the area in the past year, and has been replaced by Robert E. Blount, M.D., Acting Director and Acting Dean of the University of Mississippi Medical Center. During staff review of the application, specifically the continuation portion, the following points were made that may be of special interest to Committee and Council in reviewing this application: MISSISSIPPI RMP ~2- RM 00057 5/71 (1) The Regional Advisory Group seems to be more active in developing the direction and priorities for the Regional Medical Program. A roster of 14 new members, special orientation for new members, and a workshop retreat were factors contributing to the RAG's functioning. (2) The Core Staff has been serving in a broader capacity than before. Project review and surveillance have taken a lesser portion of time than before. Staff has been involved in a variety of joint efforts to develop activities for funding from other agencies. The trend toward full-time positions and greater emphasis on sub-area development were considered strengths for the future of this program. ° 4 ¥ (3) Health manpower remains the Region's first priority, but the focus is widening from concentration on numbers and upgrading of skills to include consideration of distribution and more effective use of minority populations as health care providers. (4) The funding request for new projects includes medical care costs, as well as training and consultation costs. This has been a recurring feature in this Region. , (5) The RAG has not taken a clear stand on phasing out RMP support. The request for three years of additional funding for the CPR project is a case in point. When this Region was originally site visited for operational status, the site visitors recommended two-year "non-renewable support" for the CPR Training project. (6) Staff's general impression of the total activities of this Regional Medical Program is that the program has been instrumental in providing consultation, training and service from the University Medical Center to all parts of the State. The training has involved other educational institutions besides the University. Projects include integrated training, patient care and consultation. FUNDING HISTORY Planning Grant Year Period Amount Funded 01 /1/67 - 6/30/68 S$ 454,206 02 7/1/68 - 6/30/69 648,607 Operational 03 7/1/69 - 6/30/70 1,229,567 04 7/1/70 - 6/30/71 1,095,428 The Region has been advised that its funding level for the upcoming year must be held to $884,037 due to overall budgetary constraints. 8 Fa 8 -_ . RECTGON MISSISSIPPT . CYCLE RM 00057 5/71 PREAZOUT OF REQUEST _ 03 PERTIGD : 9] — oo ICONTINTING | REVIOUSLY ' NEW | ; a VACTIVITILS RENEWAL NDR /UNFUN, .OTIVITTES | DIRECT ‘INDIRECT + - TOTAL rn i . i * : i : rd | CORE $362,957 5 362,957 ' $156,490 '$ 519,447 | “ ; hot -#1R Stroke Care Demon. 1 131,094 i : i 131,094 | 56,928 188,022 : a Demon, & Training in : ! ‘ an /#2R Pulmonary Disease » 178,900 ! : i 178,000 i. 72,210 | 250,210 #3 = Postgraduate Institute! 57,187 57,187 | 15,370 72,557: | #5 = Cardiovascular Clinic | 33,175 | ° 33,175 | 4,535 37,710 _| oo : : : | : ] | ' #6 = Coronary Care Unit ‘89,285 t ' i | 89,285 : 28,135 : 117,420 | oe : a 7 i i. $10 + Radiation Therapy > 45,422 | | 45,422 i; 16,565: 61,987 i — “4 | ‘ #11 - Comp. Neurology Clinic 69,040 } i i i 69,040 | 16,278 ! 85,318 | % we vee : : i i #16 - ‘Stroke Rehabilitation | | | $42,505 |! 42,505 | -0- 42,505 ! : | i #17 - Renal Disease Program - | ' 200,739 =| 200,739 69,309 | 270,048 i - — 1 1 ‘ \ . i ' : : 4 i i , : ‘ #18 - Hypertension Control 70,790__| 70,790 : 10,227 | __81,017 : : ~ : | : | #82 - CPR Program | $53,267 : | 53,267 | +0- 53,267} POR + CPR Ps - ; : i . : : i - DEVELOPMENTAL COMPONENT i : 97,518 : 97,518 | -0- i - 97,518 i 7 cat ’ : : i ‘ oO ee : 3 ea a at 1 . i \ + : x, | 8 | | ! ___ i s a 7 : : : Pog ‘ { : ‘ | > ene en —- - — ° : : NOTAL ; $966,160 . $53,267 | $441,552 $1,430,979 $446,979 | $1,877,026 | ' i MISSISSIPPI RMP : otk _ RM 00057: (5/71 ‘ : 7 . , . . . . . a _* ‘ ee mee eee ne pe eg cman ene ence ern I ewe ep ee fe c | cpppp yy Ty] | an o o / { : co wo ~ rl 4 «© at fe eee bee pee . (4 go ee fe ont oe oe ee ee eee een ae a mt ~ 4 . . aA . . 5 3 2 . a | & 3| 3 rw wt le Sls ‘| 3] < ‘ BE ei = d 2 uw o we q st ws j - o Ud fabs . Ra t cS : Hom : > oF my Be fa Ex tu << qo Ww? ee ne fie pane ewan [pee [nee emf me pn coerce ene freee me er pf ee bee te ere be cones Sm i D GY oO oO re y 3 5 << a « 7 fea 7 “ : . o fa + 3 } 7 wr Sr ee hi 2 ioc] . eb eee ee ee fae peeee pee — . 3 0 Ye fen Pree : - \ 4 4 ow $y iw $0 ch Hi oid m m i ak H> ‘a ‘ ‘ i) ’ ‘ ' ‘ fa Hi ’ ' ' 1 ’ ‘ ‘ ‘ we ' ' ‘ ‘ ‘ t ‘ 4 QV On roe] <4 o ¢ ra im < fz. s E | c4 = | 4 3 | & tH i wa Sel i a ol .a} wi me] | & & htt oO Lae ow ny uN .o re ow Lane a ra © tu ae en gs S)oosel os] smi el =| sa} al : ba et | | ° 4 O Daan ) wed . wl J Ed, food @ BREAKOUT OF REQUEST O05 reRrOD 5 a IDENTIFICATION | CONTINUING : 9 PREVIOUSLY NEW | ot | Vt ALL YEARS |! ALL VEARS | om Of COMPONENT | ACTIVITIES | RENEWAL | APPR, /UNFUN, | ACTIVITIES | DIRECT | INDIRECT | TOTAL [' preecr | TOTAL | rs i, | CORE : ! --- $362,957 _$ 519,447 _| 4 : ~ : r ; : #iR mee 4) 131,094 | 188,022 _ : } i, { #2R | | .-- {) 178,000 {| 250,210 - } : ' i \ . #3 | ae |) 57,187 | 57,187 ; #5 I ieee tt 33,175 | 37,710 i ! { i; i #6 | | wee |) 89,285; 117,420 I a #10 tomes 1) 45,422 61,987 | ~ ! q ; OE #11 ; ses |: 69,040 | 85,318 : ! - ' } . - m nano #16 i i foeee i) 42,505 | 42,505. 1 #1? | | $190,354 | $190,354 | $75,476 ,$265,830'' 575,236 | 791,067 7 : ; 3 —~ : = - #18 | 77,515 | 77,515 ; 12,193 | 89,708, 222,715 256,585 , ; a : $8R $33,320 | | 33,320) -O- . | 33,320: 129,057 | 129,057 i . | i 1 i : i : DEVEL, | j sss |) 97,518 | 97,518 | B i ~~ | ei 7 a) i i § : : , 1 ' kA i i i Li io™ | | Li jou ; ; ' - ; i> | | | | [+ { \ i - | ; : ; 7 , i | } ! ' | : | | : i . : mOTAL , $33,320 | $267,869 . $301,189 | $87,669 $388,858; $2,033,191 $2,399,093 ‘ : : i : : : ' : t | : i pe MISSISSIPPI RMP -6- RM 00057 5/71 ‘GEOGRAPHY AND DEMOGRAPHY Mississippi Regional Medical Program encompasses the State of Mississippi. Mississippi is rural in nature and rather sparsely populated with its capitol, Jackson, as the axis. Responsibility for the northern tier of counties is shared with the Memphis Regional Medical Program; according to the RAG report, that part of the State ‘ attaches itself either to Tennessee or Mississippi, whichever appears to its advantage; the two RMPs and staffs work together well. " The Regional Medical Program relates program development to the Comprehensive Health Planning and Economic Development districts where possible, but RMP activities are not bound by these areas if others seem more appropriate. Mississippi's health, education, and economic plight is a matter of public record. It is down at the bottom of the list in the ratio of physicians to population. According to the 1968 analysis of all health indicaters, only one Mississippi county is on equal footing with the top half of the nation; 62 of the 82 counties fall into the lowest one-sixth of all counties in the United States in health status. Few resources are at hand to correct this deficit. The State is 62% rural. The average per capita income is less than $1,800 per year; almost half the families have annual incomes under $3,000. Of the families in the bare subsistence category, about 53% are nonwhite and 43% are white. The illiteracy rate is about 5% double the national average with an average of less than nine years of schooling reported by Mississippi adults. REGIONAL DEVELOPMENT In November 1965 the Mississippi Heart Association invited representatives of health and civic organizations collectively to consider the potential for Mississippi of the newly enacted legislation setting up the Regional Medical Programs. Dr. Robert Q. Marston, then the Vice-Chancellor of the University of Mississippi, Congressman G.V. Montgomery, then President of the Mississippi Heart Association, and Dr. Warren N. Bell, then President of the Mississippi Division of the American Cancer Society, were asked to serve as an ad hoc committee to develop a planning group. The Mississippi Heart Association, the Mississippi Division of the American Cancer Society, the University Medical Center, and the State Board of Health each contributed $2,000 toward the cost of planning activities. Concurrently, Dr. Marston appointed an ad hoc committee categorical study groups to pool their know- ledge in heart disease, cancer and stroke as a resource for the overall planning group. In September 1966, Dr. Guy Campbell, Chief of the Pulmonary Disease Section at the VA Hospital, was employed as a half-time coordinator for the proposed Mississippi Regional Medical Program. From November through December 1966, the ad hoc study groups furnished the planners a broad assessment of the level amount, site of pertinent facilities: MISSISSIPPI RMP -7- RM 00057 5/71 and competencies. An 18 member Regional Advisory Group was designated, including 8 from Jackson, and 10 from the rest of the State. In December 1966, the RAG considered an initial draft of the Regional planning grant application which was later submitted to DRMP. After a site visit was made and consultation was provided from the Division of Regional Medical Programs, the application was revised and resubmitted in April 1967. Funding began for the Mississippi Regional Medical Pro- gram on July 1, 1967, with the University of Mississippi Medical Center as the fiscal agent. During the planning period, the Region also received funds for two feasibility studies from earmarked funds: to set up a demonstration stroke unit and a training program in chronic pul- monary diseases. Another project for hypertension control in the rural Delta County was also submitted, but not approved. The operational program application was submitted in March 1969. The Region was site visited in May 1969 and the Region was awarded operational funds on July 1, 1969. ORGANIZATION STRUCTURE AND PROCESSES The RAG now consists of 36 members, 17 of whom are new members. The geographic representation in the RAG is statewide. Eight of the members can be identified as minority representatives. The RAG consists of representatives of a variety of state organizations including Comprehen~ sive Health Planning, Medicaid, the presidents of the Mississippi College, Jackson State College, and Alcorn College, a faculty member from Alcorn, the Dean of the School of Nursing from the University of Southern Mississippi, the Acting Dean of the Medical Center and the Director of the University Hospital. The RAG has concentrated this past year in developing a plan of action for the future. Formerly, consumer members on the RAG were not involved in the program and the core staff has made a deliberate attempt to increase their commitment through better orientation. In addition, a retreat was held with the RAG staff and the Planning Committee to deveioyp clear objectives and priorities. The Planning Committee is, and has been, a key group in the organization of this Regional Medical Program. Consisting of 15 elected members from the Heart, Cancer, Stroke, Continuing Education and Hospital Liaison Committees, it represents the peer review structure in the Region. Eleven of the 15 members are from Jackson, 9 are from the University itself. Since the initial categorical committees were appointed by Dr. Marston, these committees have played an important role in the Regional development. The review process is under study in an attempt to streamline it. Briefly, the steps now involved are: the idea is developed by a proposer, the coordinator considers it, the categorical coordinators provide consulta~ tion and help, staff reviews it, a categorical committee reviews it with help from paid consultants, if necessary. Then, it goes to the Planning Committee which looks at its relevance to the program and assigns a MISSISSIPPI RMP . -8- RM 00057 5/71 priority. Finally, it goes to the RAG which studies it from the stand- point of relevance to overall goals and priorities of the program. , The evaluation of the ongoing activities and the program as a whole is also under study, with the Planning Committee taking a major role. The progress reports from the project directors are studied by staff with help from a new consultant in evaluation. Any problem areas are worked out by the staff and the categorical committees. The RAG does not appear to have a major role in evaluation at the present time. ' OBJECTIVES AND PRIORITIES . " ‘The objectives most recently defined by the RAG at its workshop retreat in December. are as follows: (1) To alleviate the health manpower shortage. (This has always been the number one priority for this RMP.) (2) To encourage improved designs for systems for health care delivery in Mississippi. (3) To provide continuing education for the health team. (4) To stimulate public education regarding concepts and resources. The priorities to be exercised in meeting these objectives include: a) incorporating minority groups in the health manpower pool, as possible; b) to make the health care delivery system receptive to the Region's necessitous citizens; c) to shift the focus of emphasis to responsible action on the local community while still maintaining regional training and consultation services as resources for local health care providers; d) to reach the functionally illiterate and stimulate an informed interest in health matters; and e) to encourage emphasis on quality, equity, efficiency, and economy in the delivery of health care. PRESENT APPLICATION Developmental Component First Year - $97,518 The Region requests $97,518 for one year for the Developmental Component. The plans are to use developmental funds for the following purposes: 1) initiate support for relevant activity when delay would be detrimental to optimal impact; 2) to deal with unforeseen problems in program implementation; 3) to enhance the effectiveness of ongoing projects by filling the gap between them; 4) to take advantage of special skills, personnel or opportunities if they become available; 5) to participate in appropriate federally-supported and other programs as they become available; 6) to test the feasibility of new program activity or concepts .by the use of the small-scale pilot projects. Developmental component funds are conceived as a tool to grasp unique opportunities not subject to nor bound by technical restrictions applicable to formal operational MISSISSIPPI RMP ~9- . RM 00057 5/71 projects. They will not be used to enlarge or extend the core staff. Any proposed activity must be consistent with the objectives and priorities and there must be a substantial probability that the activity will produce information applicable to future programmatic decisions. The application further states that the proposed developmental activity should be capable of activation with minimal delay, it should have an action component, and it should be capable of generating much more volunteer interest, involvement and participation than could be purchased on a total cost basis. The administrative procedures for ailocation of developmental component funds will be initiated by the Planning Com- mittee and approved by the RAG. The core staff will play an important role in perceiving opportunities and receiving requests for the most appropriate use of such funds and will provide the Planning Committee and the RAG with information, research and developmental services for their study. The RAG will have a developmental component study group for preliminary review of the developmental component proposals to enable the RAG prior study of the petential by their own group. Core Activities Third Year ~ $362,957 Dr. T. D. Lampton, who came to the Mississippi Regional Medical Program as Heart, Stroke Coordinator in July 1968, became the Coordinator in January. The Staff has also been strengthened by the addition of an individual experienced and trained in personnel practices, Pat L. Gilliland, named Assistant Director for Program Coordination in January. At the beginning of this current year, the core staff numbered li full- time and six part-time personnel in all categories. Two medical students were also employed during the summer. Six budgeted professional and technical positions were unfilled. In January, the staff totaled 22 at all levels, 15 full-time and seven part-time. Only two budgeted pro- fessional and technical slots are now open. Of the six professional and technical staff who are less than full-time, one is shared with the stroke unit, one is a Jackson physician, one is self-employed and three are shared with the University Medical Center. The RAG indicates they like the trend toward full~time staff. Analysis of the total core staff activities in the application indicates that most effort is directed toward: (a) project development and manage~ ment and (b) professional consultation and community relations, each accounting for some 25% of the total. About 15% each goes to: (c) program administration and direction and (d) planning studies and inven- tories. While (e) feasibility studies and (f) miscellaneous activities are estimated to absorb 10% each of the total effort. Work with com- munity, sub-regional and regional groups in development of cooperative arrangements will command greater porportions of staff effort in the coming year. By RAG direction, the field services will be expanded with the two field workers designated for this activity. The application indicates that the core staff has related to a number of different agencies within the state. For example, the core staff MISSISSIPPI RMP -10- RM 00057 5/71 helped a local medical society centralize its health and welfare information service. It helped a group called "Operation Shoe String," a local non-profit organization which provides a variety of services in a transitional poor neighborhood seek new sources of funds. The State Medical Association is exploring with the core staff the possibility of developing a utilization and review manual for primary use with peer review committee functions through the medical association. The Mississippi Dietetic Association is requesting help with the develop- ment of a dietetic manual training program for food service supervisors in continuing education workshops for dieticians. A number of planning and feasibility studies are described in the application. The core staff has served as consultants for several joint efforts, including the health law compilation with Comprehensive Health Planning, a hospital management study with the Mississippi Hospital Association and the Mississippi State University, and a survey of Lafayette County health needs with the Memphis Regional Medical Program. The University of Mississippi, the Mississippi State University, the University of Southern Mississippi, the Mississippi Research and Development Center, and core are cooperating in conducting studies in manpower development. Hines Junior College helped to structure clinical training aspects of three RMP established training programs for allied health professions. A general impression from the core progress report is that the limited resources in Mississippi contribute to cooperation among the various professional staffs. Vocational Rehabilitation, Comprehensive Health Planning, the State Board of Health, universities and other educational institutions are involved in RMP. The core staff has also been instrumental in developing a grant application to the Appalachian Regional Commission for a 20 county area. In addition, the staff has been involved in developing a maternal and child health program aimed at reducing maternal and infant deaths in a rural fiveecounty area, funded from five different sources. ONGOING OPERATIONAL ACTIVITIES Third Year — $603,203 A study 6f elected funding characteristics of the operational activities supported by the Mississippi Regional Medical Program contrasted with funding characteristics of all Regional Medical Program projects points out a revealing profile for Mississippi. Mississippi All Regions Sponsoring Agency Medical School 77% 41% Public health agencies 16% 5% Training for Health Professions Separate programs for MD's, RN's or MP's and RN's 23% 4T%, Other combination, including Allied Health, LPN's, etc. 77% 35% MISSISSIPPI RMP -il- RM 00057 5/71 Mississippi All Regions Activities Toward Target Populations Poor 43% 15% Not applicable 57% 85% Categorical Impact Heart 28% 24% Cancer Th 12% Stroke 29% 13% Pulmonary 27% 74 Multicategorical 9% 38% Health Care Impact Diagnosis & Therapeutic 734 34% The tie-in of the leading institutions and the combination of training and consultation service to target populations indicate that this Region is reaching an impressive number of communities and patients not previously served. For example, the stroke unit not only provides care to patients that was simply unavailable before, the RMP staff provides consultation to physicians and patients through a neurology project and cardio- vascular clinics planned by the State Board of Health. The Coronary Care Training project involves the University Medical Center, the VA Hospital as clinical training centers; in the first course, eight nurses from five communities, in the second - 15 nurses from 6 communities, and in the third - 11 from 7 communities have been trained. The radiation therapy project serves 51 new patients a month, compared with about 36 before the RMP support began. Family physicians have been trained, radiologists have been provided regular dosimetry service at the VA Hospital, Mississippi Baptist Hospital, and the Howard Memorial Hospital at Biloxi. The radiation therapist has provided consultation to physicians in eight different communities. The radiation physicist has provided help to nine hospitals in seven communities. New treatment centers at Oxford, Tupelo and Meridian, Mississippi are being established. Forty-two neurology clinics in 14 different locations have provided consultation and patient service Through the social worker at the Univer- sity, patients have received referral service to welfare, Crippled Children's Society, Vocational Rehabilitation, Mental Heaith and special education courses. The CPR project sponsored by the Heart Association has held 220 courses; 66 hospitals are participating. Faculty instructors have been increased from about 20 to 139. Seventy-eight hospitals now have CPR committees and 37 have code~blue procedures. NEW OPERATIONAL PROPOSALS First Year Request #16 - Statewide Community Stroke Rehabilitation Program $42,505 This is a proposal sponsored by the Mississippi Heart Association to plan the development of model stroke centers 63 Le MISSISSIPPI RMP ~12- RM 00057 5/71 in each of the health care sheds of Mississippi, to serve the diagnostic, treatment. and rehabilitation needs of patients in the surrounding areas. Funds are now requested only for Phase I of the project to concentrate on developing a protocol for optimum care of stroke patients, to recruit volunteer physicians, nurses and physical therapists for team training at the MRMP Stroke Unit as a prelude to the organization of the community stroke centers. During Phase I, community interest and involvement will be enlisted to aid in the development of the stroke units. The CPR training plan will be used as the model for the project with its "each-one-teach-one" approach and community involvement as focal . points. The proposal speaks of the neurology clinics now operating with MRMP funding, but its relation and comparative priority for the Regional Medical Program is not clearly stated. Three additional years of funding are anticipated for Phase II of the project, but the funding needs are not projected at this time. The Region anticipates putting in a request for the next three years at the time of its triennium application. #17 - Renal Disease Program ~ A version of this proposal was First Year included in the initial operational application from Request the MRMP. The site visit team learned that a chronic Hemo~ $200 ,739 dialysis Demonstration Program had been supported since 1966 and would receive partial support through 1970 through other Federal funds. (Kidney Disease Control Program, now part of RMPS has been instrumental in this support.) The site visitdrs' recommendations, supported subsequently by Committee and Council, were to provide partial RMP support for further planning and development of the training aspects of the program. The July 1970 Advisory Council reviewed a revision of the original proposal and returned it for revision. The recommendation stated that the ‘returned for revision’ was not to be construed as encouragement to submit a revision, that the concerns were related to the relation and expense of this activity as compared to other health priorities in the RMP. This particular proposal has been developed with assistance from the Kidney Disease Program Staff. To keep the unit viable during the time that the revised program was being developed, the Director, under the delegated authority, allowed the Region to utilize $47,347 in direct costs funds from carryover. This proposal thus represents a third attempt by the RMP to achieve stable support for its renal program during a period when Federal guidelines and priorities have been shifting. The proposal will be reviewed for its technical merits in relation to national guidelines by an ad hoc renal panel. The proposal is divided into three parts: I. Comprehensive Renal Training Program II. Decentralized Home Dialysis Centers III. Urinary Catheter Care “al MISSISSIPPI RMP 6 =] S- RM 00057 5/71 Earlier reviews pointed to the necessity for the Mississippi Regional Medical Program to plan its program focus in relation to resources available in nearby states, as well as within its own state. A unique feature of the earlier proposais cited by the reviewers, was related to the trailer dialysis training in communities. The present proposal includes several trainee features which may be contrary to Council policy. 02 Year - $184,143 03 ~- $190,354 #18 - Hypertension Control Demonstration - This Region submitted First Year a hypertension screening application for earmarked funds Request during its planning period. The proposal was located in $70,790 Bolivar County and was disapproved, primarily because of its isolated development and apparent lack of commitment by the practicing physicians serving in the area. The present project proposes to screen the population of Sharkey and Issaquena counties, two of the most rural, sparsely populated, low income counties in Mississippi in "an effort to determine the incidence of hypertension." Diagnosis, treatment and follow-up of hypertensive patients will be provided by the health department, the sponsoring agency, with assistance from the local medical © personnel and the University Medical Center. A letter of agreement to serve as co-sponsor is included from one of the local physicians. Aside from the objective of determining the feasibility of screening, the project's objectives include: 1) Demonstrating the ability of nursing and allied health personnel to conduct a screening program with minimum physician supervision; 2) Demonstrating that education about hypertension will increase knowledge of the public so they will seek care. Initial screening will focus on "target" groups such as public recipients, especially the disableland old age recipients. Bi~-monthly diagnostic and evaluation clinics will be held utilizing staff and residents from the University Medical Center. A screenee may elect to receive care from a private physician or the clinics mentioned above. Social service technicians will follow-up the private patients. For those utilizing clinic services, laboratory and drugs will be provided as needed. Mississippi's minimum medicaid benefits presage a large number of patients requiring drug therapy support through this project. There are no plans for phasing out this aspect of the program. 02 - $74,410 03 ~ $77,515 MISSISSIPPI RMP -14- RM, 00057 5/71 #8R - Cardiopulmonary Resuscitation Training - This is a Third Year request for three additional years for the Cardio- Request pulmonary Resuscitation Training. When the site visit team $53,267 visited the Region in its pre-operational phase, they found , that this project was very important but recommended that the project be supported for two years only and be non-renewable. Since the project began, a number of training courses have been held and 66 hospitals are participating. The next three years of the project indicate that they will extend to all of the hospitals instruction for the hospital teams and in addition, | the application states "there is a great need for training in ECPR ts to be made available to all ambulance personnel, rescue squads, 7} civil defense, fire and police departments, Highway Patrol, National Guard, utility companies and employees of their high risk industries, life guards, school officials, Boy Scouts and community groups or organizations." This aspect of the training program is contrary to Council guidelines, which-indicate that RMP support for CPR training activity should be confined to hospital-related personnel, including ambulance drivers. The proposal for the next three years does not speak to any specifics. 04 - $42,470 05 - $33,320 RMPS/GRB 3/24/71 SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE MISSISSIPPI REGIONAL MEDICAL PROGRAM RM 00057 5/71 ° FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: . Approval at the current level with advice not to fund renewal of the CPR project. The recommendation does not include consideration of the renal disease project #17 which was reviewed simultaneously by a special RMPS Ad Hoc Study Panel. The panel recommended its approval with a site visit to negotiate a reduced budget. . Support requested by the Region and recommended by the Review Committee: Direct Costs Operational Years | Requested Recommended 03 $1,430,979 $1,095,428 04 301,023 141, 623* 05 __301,, 189 oe TOTAL $2,033,191 $1,237,051 * RMPS commitment for support of the stroke project in its third year. CRITIOUE: The Review Committee noted that the MRMP is currently in its 2nd operational year funded at $1,095,428. The Region's first triennial application under the new anniversary review system, is expected at this same time next year, when a site visit will be conducted, Meanwhile the Region optioned to request a developmental component and support for new projects as part of planning that has developed this yeer, The former associate coordinator is now full-time Coordinator, His predecessor resigned to work full time for the VA, but remains on the RAG. A change in the Dean of the University is also noted, Of special interest to Committee, were points raised by staff on review of the continuation application. Although the RAG has taken on a new member, and seems more active in developing program direction and priorities; they have not taken positive stcps to phase out some current activities and move in new directions. Indicative of this is their request for renewal of the CPR project which has received support for two years, the Limit recommended by the May 1969 cite visitors, Although manage~ ment recuasdues have not been fully developed, a fairly effective core staff hes evolved and is ascending. Close working relationships are developing with eppropriate statewide liealth agencies in the state MISSISSIPPI RMP -2- RM 00057 5/71 and there is an ewphagis on sub-area development, Health manpower continues to be the Region's tep priority and success has been achieved in generating University Medical Center assistance to all parts of the state, as well as involving other institutions of higher learning. In light of the findings during past site visits, the Committee is well aware of the dearth of health care needs of Mississippi and the fact that it has only one medical school center located at Jackson, For _ this reason, as has been the case in previous reviews, the Committee was concerned about the type of activities presented for support with the limited available funds, In general, it is believed that the activities proposed are not new nor do they relate well with the stated objectives and priorities. Projects with continuation commitments probably merit continued support but the region should begin now to plan for appropriate phasing cut RHP support. Although the Region needs some funds for germinating some new and worthwhile approaches, ‘approval of a developmental component at this time is premature. The proposed new project on stroke rehabilitation relates to the ongoing “stroke care project #1R which is slated for one more year of RMP support. The hypertension project does not relate to the coronary care project and it. ig believed thet it will not provide epidemological data expected. The Committee also expressed concern about continuation of the latter after cessation of RMP support. The Committee believed the renal disezse project has merit but is concerned about the Region's hesitation to invest ite funds in more basic problem areas affecting more people. Some though that unless the Region has the capacity end/or resources, despite the renal program's excellence, it might impede the function of the Region in general. In general, the Committee believed Mississippi is making some progress, but has awesome problems and limited resources. RAG and Core have not yet developed sufficient management and evaluation capabilities to warrant full support. The Committee believed that merely taking this action and sending back the word is not enough. Direct RMPS assistance is needed in Mississippi prior’to their- submission of the next application, This might be accomplished best by a "think session" with RMPS participation and/or a pre-site visit. RMPS AD HOC KIDNEY DISEASE CRITIQUE: The panel thought this to be an. . excellent proposal, well documented, and describing an area of the country in need of assistance, It was, however, believed that the budget should be reduced “from $270,048 to a range of $75,000-$100,000. The Panel recommended approval with a site visit to negetiate a reduced budget. GRB/RMPS/4/26/71 MISSOURI SUMMARY TABLE OF CONTENTS General Fiscal Information Geography and Demography Orgahizational Structure and Processes Regional Development Planning Operational Program Early Background Computer and Bioengineering Program Community-Based Programs, including Kansas City Continuing Education Program Regional Objectives Application Developmental Component Core Computer/Bioengineering Proposals Community-Based Proposals Continuing Education Proposals Page No. ~ wo oOn~ ns 11 il 13 13 14 16 18 22 -l- (A Privileged Communication) REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION Missouri Regional Medical Program RM 00009-05 5/71 406 Turner Avenue - Lewis Hall April 1971 Review Committee Columbia, Missouri 65201 Program Coordinator: Arthur E. Rikli, M.D., M.P.H. This Region is currently funded at $3,800,000 (direct costs) for its fourth operational year ending June 30, 1971. It submits a triennium application that requests: I. A Developmental Component II. An expanded core III. The continuation of 11 ongoing activities IV. The renewal of two activities V. The activation of two Council approved but unfunded activities VI. The implementation of 16 new activities VII. The termination of 15 activities The Region requests $5,061,962 for its fifth year of operation, $4,310,940 for its sixth year and $3,511,564 for its seventh year. A breakout chart identifying the components for each of the three years follows. Several of the proposed new activities have previous review histories, which will be elaborated on later in the body of this summary. A site visit is planned for this Region, and staff's preliminary review of the application has identified several issues for the site visit team's consideration. Because of the complex nature of the Missouri program, the site visit has been divided-into four parts dealing with: 1) the review, decision-making and administrative processes of the overall program (to be reviewed in Columbia, Missouri); 2) the continuing education program (Columbia); 3) the computer and bioengineering activities (Salem and Columbia); and 4) the development of the subregional program in Kansas City. The issues related to each of these components are discussed in detail in the sum- mary and in a separate memo to the site visitors. so tete MISSOURI RMP : ~2- af RM 00009205 a FUNDING HISTORY Planning Stage Grant Year — Period Funded 01 7/1/66 - 6/30/67 $ 332,130 02 7/1/67 - 3/31/68 255,936 Operation Program 01 4/1/67 - 3/31/68 2,619 ,000 02 4/1/68 - 3/31/69 4,681,609 1/ 03 4/1/69 - 6/30/70 5,678,568 L/ & 2/ 04 7/1/70 - 6/30/71 3,800,000 05 Future Commitment for Core and 6 Projects 1,851,610 06 Future Commitment for Core and 5 Projects 1,707,075 1/ Includes a restriction of $240,343, which was placed in the 02 year, carried over to the 03 and never released to the Region. 2/ For a 15-month period. . REGION___ MISSOURI ‘ “CYCLE RM 900095771 BREAKOUT OF RECGUEST___05 _PERTOD (Trienniur) CF CONTINUING | ‘PREVIOUSLY [NEW | | ; LAGTIVITIES RENEWAL ‘APPR/UNFUN. [ACTIVITIES DIRECT INDIRECT | TOTAL SEVELOEENTAL COMPONENT 1 { '§ 400,090 |$ 400,000 -0- is 400,900 ‘CORE ($1,474,165 | L i 1,474,165 $ 356,788) 1,830,953 Ris WRU Blood "163,419 | i. 163,419 | 23. 235 )° 246,654 $50 - Stroke Prev. & Rehab, | 87,6574 T- | 87,653 | a.78 311571 #57 > teu Sikeston) i" 707,796 | { 167,796 ! aa 368 136,061 #52 - Health Careers Program: 100,777 | 100,777). 26,220: 126,997 #55 = CAMEO "Ti4,572_ | i 114,572, 15,880. 130,452 #58 - CY Edue. & Eval, 416,570 =| L 116,570 31,762) 148,332 FIG = Cervical Cytology 82,566 | i 82,566 13,380; 95,546 #27 ~ Radioisotope Program | 102,444 ; : 102,444 | 6,768: 109,212 #98">" Home Heafth Aide Proj. 141,683 =} : : 141,683 |- 45,794: 187,477 #39 + Phoncardtoscan : 37,218 ! : i 37,218 7,200: 45,118 #43 > Diabetes In Children 75,874 | } { 75,874 | 35,709 111,583 #62 = Drug Infor. Center : : $32,589 Poe 32,589 | 11,870: 44,459 #64 = Bioinstrunentation Hl 46, 834 i 46,894 i 11.794) 58,628 #O5R - Stroke ICU (3706, 964 _ [206,964 OF 372 298,935 367 - Health Ed, in Can. Hosp. | 31,079 31,079 i 6,322; 37,491 #68 - Prev. of CV Pulm. Prob. Zz r 67,148 67,148. 37,787 106,435 ‘£60 - Coon Mac. Ad ; 290,710 i 290,710 ; 51,9671 341,777 Fey a hear 58,4057 58,0057 14,1671 ‘72.372 #71 = APBAS Field Test 75,0970 75,070 ; 12,2641 87,44 #72 - Auto, Phys. Assist. : A532, 532 153,597 | 18.2707.) 971 829 #772 + Sub-Ree. Emere. Serv. | i i ! 28,888 | 28.888 : 10,168 . 49 9546 i g7h - Platelet Placmanheresis ! i i 47.427 : 47,627: Oo 274i 56.991 ‘ #75 - Biomedical Info. Serv, 1 942,698 5 942,428 | 74,916 | 417742 214_- Mobile Rehab. Service | a2 21h. 91 DIR) 97 BGO? #77 - Cardiac Care | 184.651 | 184,651} 26.481 | 221,122 £72 -_ COMPACT 5a, ban 53 440 3350p 66 842 #79 - Imnrovement of : i __-.Pheraaceutical Services hel D9 3990 20, 835 2.325. HLA - Cameron Bealth Care : ‘ . i : 11.901 ; 41,901 ¢ ° 569! 12, 470 #98) - Pranson Intensive Care: ! i 98,965 | 38,965) 6589 65.554 $22 - CE - Coordination : ! © 414,962 | 194,062 | 24,316 | 145,278 | #7 - - - Green Hits Health are. ‘ : : 95, 641 . 95,661 | 16,878! 112,523 : 1 #70 + Unassigned TOTAL © $2,606,731 $263,369 $79,423 $2,112,433 $5,061,962 S1146.117 86 ong a7q ; REGLION__MISSOURT CYCLE RM 99009" 5/71 BREAKOUT OF REQUEST___6 .___ PERIOD (Trienniun: 5 CONTINUING | iPREVICUSLY | NEW | : ic ona JACTIVITIES iRENEWAL JADPR/UNFUM. {ACTIVITIES | DIRECT !TNDIREST TOTAL i. DEVELOPMENTAL ‘ fj is 490,000 i$ 400,000 | : { TOF 1ST 687,834 | 1,687,833 | mt ; . 1 #44 179,458 i } - 179,458 Zz { 354 62,257 63.357 yg \ ' i OAS 1 85,214 } ; 85,214 i 4 £3? ! 119,145 1! i 119,145 gy Aes 26 VE | 126,111 | - BRE i 120,511 | to 120,511 | a £76 ; “ee ~ t “= wt 237 a --- | i £28 ; 22: 1 i ot Qo! i #9 --- } , com o } 74 i 81,986 i 1 , 81,986 1 ~ wn 355 | $36,984 36,984 | at ~~ £66 : | 47,708 i G7, 708 a F25R : - | $52,272 $ to 52,272 3 i ' #67 _ i 33,536 33,836: >! - 368 ; r 67,995 67,095 ; zw | ’ — #59 : 173,822 TE B22: a #25R ! i 52,364 | 1 __ 52,364: 47 ; --- | --- z 372 i : i =-- i ~=- °o | 473 : = ‘ Tees i a B76 37,595 37,595 ! : | . £75 _ it Y 288,449 288,440 } a #76 : ~~ 94,625! 94,625 ; "3 477 : . : 159.554 : 459,554! oI | aya * 47,480. 67.489 - a \ iT9 | ' i, 72,610 + 73,610 3 H X #e0 { | | 1N,462 ! 10,462 | d #2] i 28.469 : 28,460! me 282 a ; m 942,949 * —-142,940 ! tg | #73 : 95.077 95.977 | v ‘ #70 - Unassigned : : . : ‘ : \ ; ‘ j : TOTAL $2,463,615 '$104,636 | $84,692 1$1,657,997 $4,310,940 1 . : ; |. ‘ ! : | . agen 4 Agee oe / o oe ail "RM 00009 5/71 BREAKCUT OF REQUEST 07 PERIOD IGENTIFICATION | CONTINUING - PREVIOUSLY NEW ; ALL, YEARS ALL YEARS OF COMPONE TIES | APPR, /UNFUN, ACTIVITSES DIRECT INDIRECT | TOTAL |; DIRECT TOTAL DEVELOP ‘ 40n, 009 “ 4090, aan 1,200,900 > 262 277 tt 51,0 192,619: 240. 68% 3 “82,566 & 7 141,687; : 157,860 “Goa Loe : : 738 w . 44,801 ' 259,235 | 110,000 134,243 | $52,287 . 163,056 ; wwe --- ; 28,888 | 259,440 259,44 890,308 --- --- ; on 153,822 153, 82 : . 498,027 | 4 4 q 73,619 73,61 : 221,210} 0 3 0,46? - 4 273 9,909: 9,90 76.4253. : i 22 2 95,077 . 95,9 : ‘ 285.815 | : ty $52,287} $.5,424 | $1,473,236 :$3,511, 564 _br2yant. ase . : i | | IRB 3 yyy) | 2 i ‘ i i Missouri Regional Medical Program -6- RM 00009 5/71 GEOGRAPHY AND DEMOGRAPHY ‘The Missouri RMP boundary is roughly that of the State's, except for forty-two counties in the St. Louis area. The population of 2,849,594 occupies a land area of 69,138 square miles. The Region is 58% urban and roughly 93% white. The Missouri RMP has established some relationships with the neighboring RMP's of Kansas, Bi-State, Iowa, Oklahoma, Arkansas and Memphis. Coordination of MRMP and KRMP activities in Kansas City is effected through a CHP b Council in Kansas City. A working relationship has also been established with the Memphis RMP in southeast Missouri. The MRMP includes two medical schools and two colleges of osteopathy: the University of Missouri Medical School in Columbia with an enrollment of 412, the University of Missouri Medical School in Kansas City with a projected enrollment for its first class (Fall 1971) of 36, the Kirksville College of Osteopathy and the Kansas City College of Osteopathy. The Region has 18 schools of nursing--four baccalaureate, six associate degree and eight diploma schools. There are also 13 medical technical schools including 11 baccalaureate and two diploma programs. General hospitals (including osteopathic institutions) total 130 with 15,012 beds. There are also two Veterans Administration Hospitals with 728 beds. (The figures for all hospitals exclude extended-care facility beds). Missouri is served by 2,414 practicing physicians (there are a total of 2,571 in the Region); 901 active doctors of osteopathy (total 959); 5,678 active RN's (total 8,518); 4,082 active LPN's (total 5,233); and a total of 31,864 other allied health personnel. ORGANIZATIONAL STRUCTURE AND PROCESSES The Missouri RMP "Regional Advisory Group" is a three-part organization composed of a Regional Advisory Council, a Project Review Committee, and a Liaison Committee. The RAG as a whole is designed to establish overall policy and to review project proposals. The RAC has 12 members appointed by the Governor from candiates recommended by the Project Review Committee. Robert E. Frank, Director of Barnes Hospital in St. Louis, has moved from membership on the RAG to the chair- manship, replacing retiring chairman, Nathan Stark. Other members include: 5 practicing physicians, 1 osteopath, 1 sociologist (Black), 1 State Senator, 1 State Representative, 1 attorney and 1 businessman. The RAG provides overall guidance on policy, program planning, development and operation of MRMP. Based on recommendations and priorities of the other two RAG components and the local District Liaison Committees, the RAG sets its own pricrities on projects and makes recommendations to the National Advisory Council. i Missouri Regional Medical Program -7- RM 00009 5/71 The Project Review Committee has nine members who represent the four medical and osteopathic schools, and the directors of the Missouri divisions of Health, Mental Health and Welfare. This Committee assesses project proposals and other policy matters on merit, establishes priority ratings and forwards these with its recommendations to the RAG. It also recommends candidates to the Governor for RAC membership. The Liaison Committee consists of representatives from 23 voluntary and professional health agencies. This Committee provides recommendations to the RAC on project value and their relevance to the represented agencies, besides serving as a two-way communications link between agencies and the MRMP. In addition to the three RAG components, there are District Liaison Committees presently in three of the six MRMP areas - Kansas City, South- west and Southeast, and similar committees are being planned for the other areas. Each committee is responsible for providing recommendations regarding lo¢al need for projects proposed from its own district and impact on other areas, as well as for developing its own district policy. The Greater! Kansas City Liaison Committee has been replaced by a group nominated by the local CHP "B" agency--an arrangement also being considered by other districts. REGIONAL DEVELOPMENT I. Planning - Planning began in Missouri in April 1966 with the submission of a planning grant application by the Program Coordinator, Dr. Vernon Wilson, The reviewers of the application commented that: 1) planning for and representation of the St. Louis area on the RAG seemed weak (the Bi-State RMP later encompassed this area); 2) the program was vaguely defined; and 3) the apparent emphasis on community service was most impressive, although not well-budgeted for. The award was made in June 1966. Il. Operational Program A. Early Background - In October 1966, the Region submitted an application for three operational pilot projects, which was deferred for a site visit. At the same time DRMP suggested to the Region that a more comprehensive operational grant application be prepared, with the possibility of the MRMP becoming one of a few "model programs." The Region explained at a site visit in 1969 that Dr. Wilson gathered together several members of the University faculty interested in RMP and spent "forty days in a pe-3" with them traveling around the United States looking at possible types of innovative projects to develop. The Region then submitted an application containing 20 additional projects, three of which were community programs, three population and data studies and the rest computer and bioengineering activities. Submitted at a time when the RMP budget for 1970-71 was projected for $200 million, the intention of these latter proposals was to use the computer and bioengineering resources at. the University to develop and deliver diagnostic and therapeutic assistance to practicing physicians isolated from the medical center. The Region was site visited in November 1966 with a favorable report, and the Region became one of the Missouri Regional Medical Program -8- RM 00009 5/71 first RMP's to become operational when the award was made in April 1967, at a level considerably below that requested. Three conditions were placed on the award: 1) the RAG add minority group representatives; 2) more attention be given to the urban ghetto areas; and 3) more emphasis be placed on cancer programs. During this same year two supplemental applications for project support were submitted: Project #19 - Automated EKG in a Rural Area, was approved and a proposed stroke center at Kansas City General Hospital was disapproved. At the beginning of the second planning year (July 1967), another site visit was held to look at several supplemental project requests. The visitors were impressed with the concept of regionalization and the Region's intention to phase-out RMP support after three years of funding. In October 1968 Dr. Arthur Rikli replaced Dr. Vernon Wilson as Coordinator. At this point in its history, the program seemed to reviewers to separate into decided program areas. A. Computer and Bioengineering Activities Eight projects were funded in this area: multiphasic screening, mass screening - radiology, automated patient history acquisition system, data evaluation and computer simulation, computer fact bank, operations research and systems design, bioengineering and automated EKG for rural areas. Both DRMP and MRMP realized that these were developmental activities, but both hoped that after three years, they would be able to make definite contributions to the delivery of health care. At that time of the second year's continuation review of the original projects, the Region submitted a request for $860,000 more than the committed level, torexpand computer and bioengineering activities as originally planned. A restriction of $240,483 primarily for A and R, which involved computer facilities,was placed on the award, and a technical site visit was recommended. Although the Fall 1968 visit was only for one day, reports of progress on the individual activities were discouraging. Within the next few months, the Region proposed support in their third operational year for a élinical core resource which involved approximately $800,000 for staff in the computer/bioengineering projects in addition to the ongoing projects in this area. As a result of the critical site visit comments and the uncertainty about the concept of clinical core, Council recommended that these activities be reviewed in depth during a site visit that year. In October 1969, a major site visit was held which included three peer reviewers with expertise in computers who spent two days assessing the activities. As a result of the site visitors’ conclusion that none of the activities had yet demonstrated success in improving the delivery of health care or in enhancing regional, cooperative arrangements, Council in March 1970 recommended that the Region reduce its expenditures for these activities and then phase-out RMP support completely by June 30, 1971. The project was awarded approximately $1, million for its fourth and final year of operation in order to combine the former eight parts, to make the Missouri Regional Medical Program -9- RM 00009 5/71 system compatible, and to field-test the module in one physician's office in Salem, Missouri. At the time of staff review of the last application from Missouri in July 1970, RMP staff requested additional information about the Advanced Technology Proposal. The Region's replies raised concerns which rélated to: 1) the liklihood that the components would be completed, made compatible and fully operational in the private physician's office in Salem in sufficient time to test enough patients to obtain meaningful results within the project time period; 2) the coordination necessary to cohese so many different elements; 3) the detail and comprehensiveness in workscope timetables and planning needed to bring the divergent subprojects together in an orderly and coordinated manner. The Director, RMPS, recommended that the Region call in outside experts in systems design and computers, epidemiology and clinical medicine to review, monitor and make suggestions for appropriate changes in order that the project would be completed by June 30, 1971. A site visit including Dr. John Hirschboeck, Wisconsin RMP Coordinator and a member of the October 1969 site visit team; Dr. Morris F. Collins, Director Medical Methods Research, Permanente Medical Group and Dr. Martin D. Keller, Department of Preventive Medicine, Ohio State University, was held by the Region to the Salem operation in January 1971. The report, a copy of which has been forwarded to RMPS, is enthusiastic about the results. The Region's proposal for continuing these activities is discussed on pages 16-18 in the summary. B. Community-Based Programs MRMP's early efforts in developing community-based programs were in Smithville and Springfield. Smithville in northwest Missouri evolved and was praised by national reviewers as a model for small communities in developing total care facilities, including continuing education opportunities, which have become self-supporting and cost-efficient. The Smithville project began in April 1967 and terminated after three years of support. The Springfield Cardiovascular Program in southwest Missouri was an early effort in building linkages to rural practitioners. The project, which was expanded and reviewed as Project #58 in 1970, appeared to _ site visitors to be an effective instrument for subregionalization of health services and education. There were other early subregional efforts such as a Comprehensive Cardio- vascular Care project at Kansas City General (#27), a stroke pilot project at the Kirksville Clinic of Osteopathy and Surgery (#28), a regional program in rheumatic fever prevention using a detail man (#32), and a radioieotope cancer program in Cape Girardeau (#37). In the Region's third operational year (1969-70) the subregional projects began to experience some difficulty during their review at the national Bese, ee - Missouri Regional Medical Program -10- RM 00009 5/71 | level, which had profound repercussions in the Region. At a time when ~ the computer and bioengineering activities were being funded at a / $2,4 million level, the disapproval in two review cycles of an intensive care program in Sikeston, a stroke program in Joplin, a coronary care unit in Osceola, and a comprehensive rehabilitation program in Lebanon, inadvertently conveyed a false impression to the Region of the ~~ national reviewers' wishes concerning the future emphasis of the Program. . While each project was viewed individually and returned for substantive _ technical reasons, the cumulative effect on the Program of these individual actions was unfortunate. The site visitors in October 1969 heard repeatedly about the Sikeston community. After a study of the site visit findings concerning the discouraging results of the computer bioengineering investment and the lack of emphasis on community-based programs, Council in December 1969 recommended that the Region févise and resubmit these conmmunity- based projects during the next review cycles. In the February-March 1970 review cycle, Council did approve the resubmissions from Joplin (#50) and Sikeston’ (#51) and a renewal of the Springfield effort (#58). The Region's community-based requests since then have not fared so well. The Region submitted a comprehensive health care system proposal for the Cameron Gommunity in northwest Missouri (#60), an intensive care and rehabilitation project in Branson in southwest Missouri (#61), and a comprehensive health care system proposal for eleven hospitals in the Green Hills area (#65). While Council recognized the earlier advice to the Region to éncourage community development, it was concerned with the types of support requested by the Region in each project. Items such as equipment, staffing for provision of services and a communications system for centralized cost accounting, reviewers felt should be under- written by the hospitals and not by RMP. In addition, weaknessés in documenting need, describing what would be done and how it would be evaluated indicated the need for more assistance from the MRMP Core staff. The Region's revised submissions of these proposals are summarized in pages 20-21 of this summary. Descriptions of new activities in this area are on pages 18-20 of this summary. Until the last year there was little evidence of RMP activity in Kansas_ City, other than the cardiovascular project at Kansas City General (#27). The October 1969 site visitors found that the Gore office was not staffed, and the Kansas City Liaison Committee had become inactive. However, with the development of a new medical school in Kansas City and the proposed involvement in the Wayne Miner Neighborhood Health Center through the Hi-Blood project (#46), prospects looked favorable. During the past eighteen months, the Kansas City Core office has been staffed and the CHP b Council now serves as the liaison committee for MRMP and KRMP in Kansas City. A Core supplement was disapproved by the November 1970 National Advisory Council because the proposed activities were too diffuse and did not appear to be correlated with the rest of the MRMP. This application again proposes supplemental core funds for Kansas try and two projects, #78 and #79 described on page. 93 of this summary. Mes Missouri Regional Medical Program _-ll- RM 00009 5/71 D, Continuing Education and Training — The third major aspect of the Missouri program has been continuing education. While not designated as such, many projects had continuing education or training as a major feature. There seemed to reviewers and site visitors to the Missour{ program to be two concurrent and separate trends in this area developing in the Region. One was the excellent efforts fostered by individual project directors independently of the University ins projects such as Smithville, Springfield, and Cape Girardeau. The other was the University-connected activities, such as the stroke ICU and cardiac ICU training proposals at the medical school (#25 and #26) and the telecture series, which linked community hospitals throughout the Region with the medical school by two-way radio (#33). This side of MRMP's continuing education program seemed to be supporting continuing education competence within the medical school without building any visibility for RMP. - A Core-Continuing Education resource based at the medical school was submitted by MRMP in mid 1969. Its lengthy review history is described on page 23 of the summary, but its difficulties in gaining approval may be attributed partly to its emphasis on developing an institutional organization to provide continuing education rather: than developing programs which would focus on improving patient care. Other factors, including the size of the request, are discussed as background to the revision in this application. Other proposals denoted by the Region as primarily continuing education are included in this section. In conclusion, this Region is at a critical point in its history. Over a year has elapsed since the major program site visit and the Review Committee and Council review which made substantive recommendations about the direction of the program. The Region is now preposing a three-year plan which is an outgrowth of its total experience since 1967. The regional objectives and the three-year plan to address these. objectives follow. Regional Goals The Missouri RMP has developed the following program goals: 1. Through cooperative arrangements to accelerate health and medical innovations and demonstrations. 2. To develop a balanced program of problem-and-patient-care oriented continuing education for health professionals. 3. To develop a relevant data base and the data hasdling capability to permit effective project and program evaluation. 4. To stimulate the prevention and early detection of heart disease, stroke, cancer and related diseases. ' Missouri Regional Medical Program -12- RM 00009 5/71 5. 10. ll. To stimulate lay health education - information programs, emphasizing prevention and early detection of diseases. To strengthen the diagnostic and treatment capabilities of the region with respect to HSC & RD.. To expand and strengthen long-term-care, rehabilitation and . home care for HSC &-RD. To develop a comprehensive health services project in each of the six subregions. To facilitate health manpower recruitment, thus helping the physician make optimum use of his knowledge and skills. To achieve close coordination with other health and health-related programs. To co-sponsor activities and programs with neighboring Regional Medical Programs. Missouri RMP -13- RM 90009 «=5/71 PRESENT APPLICATION Developmental Component First Year Second Year Third Year $400,900 $400,000 | $400,000 The Missouri RMP states that its developmenta] component activity is expected to have two benefits: greater responsiveness of ‘the MRMP's objectives to changing regional needs, and increased effectiveness of the MRMP nrogram in achieving these objectives. Proposed developmental activities include: 1. Providing opportunities for a wider variety of professional and lay input into the Region's decision-making bodies in regard to reshaping objectives. , The Region might provide part-time support and secretarial service for one member each from the law school, an allied health profession, or a minority group, who would study RMP legislation and the bealth care system from their vantage point, recommending fresh approaches. This might lead either to revamping of objectives or to proposal develop- ment. 2, Selectively supporting the development of proposals which specifically address regional objectives. Developmental component funds might be used to encourage development of the most relevant projects proposed to the Region by letter of intent each year. Support would include part-time support of the project director, support for a research associate, secretarial help, evaluation consultation, and for activity required to obtain co-operation and coordination in the project area. 2, Funding surveys and feasibility studies to ensure development of proposals which would be more effective in reaching program objectives. Develonmental funds might support both the studies which would validate the assumptions usually made about expected benefits of proposed active ities. as well as the data-gathering activities necessary for developing and evaluating a proposal being written or considered. 4, Funding activities which would themselves lead to achieve- ment of Regional objectives. This would allow greater flexibility in the Region program. The develop- mental component could provide total] support for short-term projects of limited scope, as well as partial or complete support of projects awaiting RMPS approval should the RAC consider earlier funding necessary. Missouri RMP ~14- RM 90009 5/71 Administrative Procedures for Allocating Developmental Component Funds The Developmental component will be managed primarily by core staff. Requests will be submitted for approval to the RAC, and funds awarded and managed by the regular administrative support system. Fifth Year: $1,474,165 The Core of the MRMP. has been organized into three offices: CORE 1, The Office of the Coordinator, which provides administrative support and professional consultation in electronic data processing, fiscal affairs, information and management. An Associate Director for Continuing Education, who will be responsible for all continuing education activities in projects and in the district offices, will be added to the Office of the Coordinator. Fifth Year Request $647,795 9. The Office of Operations, which is primarily responsible for program implementation and evaluation. When projects have been funded, the Office coordinates and monitors the progress of ongoing projects through in-house site visits in the next-to-the-last year of the projects, district project directors meetings, and project directors meetings via the telelecture network (not yet initiated), This Office also requires quarterly progress reports. In order to help regionalize some of the results of the bioengineering projects, the "detail man" of the MRMP- funded rheumatic heart disease project has been added to the operations staff. Consultents are made available to project directors in the areas of communications, continuing education, medical and scientific affairs, hospital and allied health affairs, computer science and evaluation. Fifth Year Request $181,981 2, The Office of Planning, which develops an overall MRMP plan and major disease category plans to be implemented through projects. This Office works with veople developing proposals and staffs the meetings of the MRMP Acvisory Council, Project Review Committee, Liaison Committee and Subregiona! Liaison Committee. The Program Methodology Unit, formerly funded as a project and with expertise in epidemiology, statistics and data processing, is incorporated into the Planning Office. It provides various data for project purposes and for the RMP's planning purposes by ucilizing existing sources of data and occasionally collecting its own. Evaluation is also the responsibility of the Planning Office. Although presently placed within the Planning Office, it appears from the organizational chart on page 51 that the district offices will be made Missouri RMP. -15- RM 90009 5/71 directly resnonsible to the Coordinator. District consultants have been chosen for each of the districts (Kansas City, Northwest, North- east. Southeast, Southwest and Central). District offices in addition “to the Kansas City office will be developed over the next three years. Fifth Year Request $458,113 The Kaneas City Area Planning Office provides planning activities for the five-county areas of Jackson, Clay, Platte, Ray and Cass Counties in support of MRMP activities. Its staff includes a Planning Director, Assistant Directors in communications, community services, allied health and professional relations. Activities of the Kansas City Area Office (described in pages 164-175 of the application) include efforts in nlanning physician's assistants program, restructuring nursing curriculum at the junior college level, developing career: Jadders for L,P.N.'s and studying the feasibility of a two-way medical TV network. Fifth Year Request $186,276 Coordination and some overlap of membership is planned between the MRMP area committees and CHP (b) councils. The experience of the University Extension Division, which has offices throughout the state, will also be used in developing public education programs at the subrepgional level. The MRMP Core has also been administering the state's $200,000 appropriation for hemodialysis and is presently involved in developing a multi-regional renal disease program with the Kansas and Bi-State RMPs. The total number of positions requested is 89 (71.5 F.T.E.): of these 80 positions, 58 are presently filled. Sixth Year — Seventh Year $1,687, 833 $1,896,617 Descriptions of these terminating Program Guidance Projects can be found in the application following the core section. #2 - Communications Research Unit #12 = Population Study Group Surveys #14 - Automated Hospital Patient Survey © Projects The Region has organized the discussion of their projects into various subject areas in their application. In describing the proposed activities in the summary, Staff has changed the Region's arrangement somewhat, in order to better align the project discussion with the background Missouri RMP -16- RM nn0n9 «5/71 material. The three major sections are: Computer and Bioengineering Projects, Community Service Projects and Continuing Education Projects. Computer_and Bioengineering Projects While the Advanced Technology Project and its eight components (Mul ti- phasic Testing, Mass Screening Radiology, Automated Patient History Acquisition System, Data Evaluation and Computer Simulation System, Computer Fact Bank, Operations Research and Systems Design, Biomedical Engineering and Automated EKG in a Rural Area) are terminating as such, the work begun during the past four years will be continued in the following five projects: . Requested First Year Project #64 - Bloinstrumentation ; $46, 834 This project was previously approved by Council but has not yet been funded, It was developed a6 a result of one of the recommendations of the October 1969 site visit report which urged that the medical instrument- ation services of the biomedical engineer in the Biomedical] Engineering Project be made more widely available to hospitals throughout the Region. The project would help regional hospitals optimize their utilization of patient monitoring instrumentation by: . 1) Giving engineering counsel in ICU-CCU design and in the selection of biomedical patient care instrumentation, thereby assuring , patient protection against accidental electrocution; 2) Providing specialized instruction for engineers and technicians in routine maintenance procedures, recognition of substandard oneration and safety practices; and 2) Conducting seminars on request within regional institutions to instruct medical and paramedical members in techniques for optimum utilization of their patient care instrumentation. Second Year Third Year $47, 708 $50, 259 Requested First Year Project #69 ~ Computer Processed Diagnostic Aids $290,719 in a Rural Area This proposal is an extension and field testing of the automated electrocardiogram with the addition of new diagnostic aids, including artificial pacemaker analysis, cardiac arrhythmia analysis, exercise ECG analysis of lung function by spirogram and screening analysis of the phoncardiogram. The project plans for 38 stations and 50,000 ECG's per year. A special aim would be to provide aid to the smallest medical Missouri RMP | -17- RM 00009 5/7] facilities -~ community hospitals under 100 beds, group practicies and solo practitioners - at a reasonable cost. The proposal also offers training for medical and electronic service personnel. Second Year Third Year $178, 882 , $122,715 . Requested First Year Project #71 - Automated Patient History Acquisition $75,070 System Field Test The purpose of this proposal is to field test this approach to acquiring @ medical history in the offices of a three-man internal medicine group nractice in Cape Girardeau. The APHAS program has designed the question- naire in layman's language with anatomical sketches and cartoon characters and a computer program to present these questions on the computer terminal. When the patient finishes the questionnaire (usually in 45 minutes), the computer prints out a summary of the patient's responses to the questionnaire as well as the positive responses to symptoms of diseases for the anatomical area troubling them. Some preliminary evaluation has been done of the patient's responses. Requested First Year Project #72 - Automated Physician's Assistant $153,537 The project would attempt to determine the effectiveness of a computer-~ related system of medical tests designed to function as a "physician's assistant.'"' The total package would consist of the APHAS questionnaire, an EKG, 12 blood chemistries, blood pressure, height, weight, eye test, hearing test, chest X-ray, spirometry, tonometry, Achilles tendon reflex and a phonocardioscan, A prototype of this system which is presently installed in a physician's office in Salem, Missouri, is funded until June 30, 1971. Further support is requested to test the effectiveness of each of the components and permit further evaluation of the system by the physician and his patients. Requested First Year Project #75 - Biomedical Information Service $342 ,428 Formerly known as the Computer Fact Bank, the Biomedical Information Service proposes to tie together library activities and systems for information coordination and transmission. While the present system has developed a system of storage and retrieval of biomedical information with ten onerating outlets in the Region, the BMIS would utilize the 192 telective units, 15 teletynewriter units of the ECG project and 2? satellite Extension Health Information Centers to be develoned, The proposal hopes to increase smaller medical library utilization by: 1) holding workshops, in-service training and continuing education sessions for library staff personnel, hospital administrators and physicians; 2) arranging for interlibrary loans, information exchange and bibliographies and specific literature; and 3) provision of con- sultation services. Second Year Third Year , $259,440 Missourt RMP -18- RM 00009 5/71 The MRMP Advisory Council has recommended that this proposal incorporate the services of the Health Sciences Libraries System and the Drug Information Central (#62). Community Service Projects The terminating project is: #29 - NE. Missouri Cooperative Stroke Pilot Project Continuing Projects with Committed Support are: #46 - Hi-Blood #50 - Joplin Stroke Prevention #51 - Sikeston Intensive Care Unit #52 - Health Careers Continuing Projects with no committed support (these proposals were originally approved but unfunded; however, the Region has elected to initiate them with carryover or by rebudgeting): #36 - Missouri Cervical Cytology #37 - S.E. Missouri Radioisotope #38 - Homemaker Health Aide #39 - Phonocardioscan #43 - Diabetes in Children #62 - Drug Information Central New Projects In these projects, the Region provides services either to several locations or for the entire region on a community basis as part of a plan to extend regional activities to the patient's bedside. Projects #76 (Mobile Rehabilitation Service) and #77 (Cardiac Care _Missouri) both relate to objectives: 1) cooperative arrangements; 2) continuing education; and 6) diagnostic and treatment capabilities. Project #76 also relates to objective 7 - rehabilitation and home care. Project #68 (Cooperative Prevention for Cardiovascular Pulmonary Problems) includes not only objectives 1,2,6, and 7 but also objectives: 4) prevention and early detection; and 5) lay education. Project #80 (Cameron Health Care) is related to 10 of the 1) Regional objectives and #81 (Branson Intensive Care) includes all 11 of the Region's objectives. Project #25R- (Stroke Intensive Care) relates to Regional objectives: 2) continuing education; 6) diagnostic and treatment capabilities; and 8) development of community health services. Missouri RMP ~19- RM 90009 5/71 Project #48 - Cooperative Prevention for Cardiovascular Pulmonary Problems This project would involve hospitals in the Kirksville area serving seven counties in Northeast Missouri. It is based on the Northeast Missouri Cooperative Stroke Project (#29) now terminated. Objectives of the new project are: 1) initiation of innovative continuing education ’ programs for physicians and allied health personnel (coordinated with Columbia and Springfield graduate nursing courses) and a community education program emphasizing prevention; 2) development of a preventive and therapeutic activity center in collaboration with the Division of Health and Physical Education of the Northeast Missouri State College; and 3) establishment of progressive care and rehabilitative programs for cardiovascular-pulmonary patients as a part of the new expansion at the Kirksville Osteopathic Hospital. First Year Second Year $67,148 $67,095 Project #73 - Regional Emergency Service Quantitative Upgrading (RESQU) This is a planning effort, involving an eight-county rural area of . Southwest Missouri, which would establish an organized ambulance service capable of getting patients to medical facilities in optimum condition. Upon successful implementation in these counties, the program would be expanded to the remaining 25 Southwest counties, First Year , Second Year $38,888 7, Project #74 - Platelet Plasmapheresia Program This project will establish an efficient, full-time and ultimately self-sustaining plasmapheresis program in the southwest Missouri subregion. When implemented at St. John's Hospital in Springfield, the program could accommodate patients in any southwest hospital where platelet transfusions are done. Primary purpose of the project will be provision of compatible platelet infusion. Tissue type and histo-compatibility techniques would also be initiated along with this project. Firat Year : Second year $47,627 $37,595 Project #76 - Mobile Rehabilitation Service This project would provide rehabilitation services, now unavailable to rural areas of southwest Missouri, by establishing a mobile service under the supervision of an orthopedic surgeon and in consultation with a Missouri RMP -20- RM 00009 5/71 physiatrist. Two teams, each composed of a physical therapist and a nurse's aide (with part-time access to an occupational) therapist), would provide 20 days of service each month to outlying hospitals and nursing homes. First Year Second Year $93,276 $94,625 Project #77 - Cardiac Care Missouri This project is designed to provide improved care to patients with acute cardiovascular illness through: assessment of present care and consultation on corrective measures; coordination of ongoing programs; education of providers, patients and their families; establishment and improvement of communication (such as tele-transmission of EKG's); and assistance in arranging continuing clinical consultation. The project structure will include a Missouri Heart Association "task force", providing assistance to any community or subregion in Missouri, and cardiovascular care committees in each participating hospital rehating both to volunteer staff in each subregion and to an MHA Cardiovascular Care Committee of 12 local physicians, Initially, project activity would concentrate in southeast Missourl. First Year Second Year $184,651 . $159,554 Third Year $153,822 Project #80 - Cameron Health Care This is a revision of a previous submission which was disapproved because of weaknesses in evaluation and educational design and because it requested support for services which. should be financed by the community. Based at the Cameron Community Hospital, this project is designed to upgrade, through physician education programs, the diagnostic and treatment capabilities in categorical diseases of 13 area private practitioners and to organize and train supportive medical personnel. The use of consultents from neighboring institutions should help reduce the isolation of the private practitioners. The project will also provide: appropriate patient care equipment from hospital funds, effective emergency care in ambulances, rehabilitation services, and trained personne! for follow-up care through a home health agency. First Year Second Year $11,901 $10,463 Third Year $10,463 Project #81 - Branson Intensive Care and Rehabilitation Project This revised proposal was turned down originally primarily because it: appeared to represent the interests of a single institution, rather than a truly regional effort. Missouri RMP ~21< RM 00009 5/71 This project is designed to provide immediate access to high quality, low-cost health care at the Skaggs Community Hospital, establishing cooperative arrangements with referral centers, with special emphasis on improving service to the large number of elderly disadvantaged and rural. poor in the area. To do this, the project provides for both training and continuing education of nursing personnel technicians and Doctors of the hospital medical staff. Consultants wil] be drawn from St. John's Hospital, Springfield (intensive care) and the U.M, Department of Physical Medicine (rehabilitation). The project will include evaluation of post-treatment results compared to past results and results at other hospitals. First Year Second Year $38,965 $28,460 Third Year $9,000 Project #83 - Green Hills Cooperative Health Care Project Disapproved by the November 1970 National Advisory Council because it also requested support for services and equipment which would ordinarily be underwritten by the hospitals, the project has been revised and resubmitted by the Region. This project is designed to combine the resources of 11 cooperating hospita’s in the 12-county Green Hilis medical service area to ensure improved quality and quantity of health care, with efficient, economical use of resources and comprehensive care for the entire area. This effort will require establishment of a communications network serving all 11 hospitals, and development of: techniques for continuing education of all medical personnel, adequate ambulance service, adequate coronary and stroke emergency care in al] hospitals, an areawide inhal- ation therapy program, an areawide comprehensive rehabilitation service, and a home health agency for the area. First Year , Second Year $95, 661 $95,077 Third Year _$95,077 Renewal Projects Project #25 R - Stroke Intensive Care Unit This project, located in a temporary unit at the UMMC, will continue to examine the effects of stroke intensive care nursing on mortality and morbidity of stroke patients. Presently, personnel in the temporary Missouri RMP -22- RM 00009 5/71 unit have become efficient with the electronic equipment and are preparing for the opening of a new ICU. Nurses have already demonstrated ability to detect new or progressive neurological changes in the stroke patient. Of the 15 patients admitted to the ICU, twelve survivied; while of the 16 admitted as a control group to the regular care group, nine survived, Continued random admissions to the ICU and increased patient referrals will provide an opportunity to conclusively document these results. 7 Fourth Year ‘ Fifth Year $206, 964 / $52,272 ’ Continuing Education Projects The terminating projects are: #27 - Programmed Comprehensive Cardiovascular Care #33 - Continuing Education for the Health Professions (telelecture) Continuing Projects with Committed Support are: - #55 + Cameo #58 - Cardiovascular Education and Evaluation New Projects The new continuing education projects in this application include a variety of proposals which address themselves to in-service training, improvement of health care problems related to laboratory services and two regional approaches to the organization of continuing education. Projects #79 (Improvement of Pharmaceutical Services) and #78 (COMPACT) are related to objectives: ~1) cooperative arrangements and 2) continuing education. Project #70 (Training in Arrhythmia and Resuscitation) also relates to objective 2. Project #67 (Health Education in Cancer Hospital) relates not only to objective 2 but includes aspects of: 9) health manpower; 6) diagnostic and treatment capabilities, and 7) rehabilitation and home care. Project #67 - Health Education in A Cancer Hospital Setting This project is a trial of comprehensive health education in a hospital setting, Ellis Fischel State Cancer Hospital in Columbia, This effort will include development, implementation and evaluation of education programs for patients and their families, al] hospital employees, and the public, Within two years, concepts developed in. this project will be shared with other facilities in the State through workshops and consultations. First Year Second Year $31,079 $33,836 Third Year Missouri RMP -23- RM 00009 5/71 Project #78 - Cooperative Ongoing Medical Health Participation and Continuing Teaching This project wil] establish regular inter-hospital departmental meetings to upgrade educational programs in metropolitan Kansas City hospitals which will be utilized by the new medical school for clinical teaching. COMPACT wuld coordinate meetings of each specialty in conjunction with joint hospital departments so that multiple hospitals would be represented. A review, or coordinating, committee for each specialty or department would coordinate clinical review with a scientific session. Each department, then, would share in eight joint meetings annually, as well as in four administrative meetings at their respective hospitals. First Year. Second Year $53,440 $47,480 Third Year $47,778 Project #79 - Improvement of Pharmaceutical Services - Rural Health Care Institutions Sponsored by the University of Missouri (Kansas City) Schoo} of Pharmacy and Division of Continuing Education, this project will evaluate pharmaceutical services in hospitals and nursing homes - particularly in rural areas - to determine for each: current status of services, facilities available for such services, and local pharmacists available to provide proper services, This information will be used to plan and implement needed improvements in each institution through a cooperative effort of project staff and institution personnel. First Year Second Year $73,990 $73,610 o Third Year : $73,610 First Year Project #82 - Continuing Education ~« Coordination Project $114, 062 This proposal has hed a lengthy review history. Originally submitted in mid-1969, it was deferred by Council for further consideration by the October 1969 site visitors, reviewed at the site visit, returned for revision by the December 1969 Council, resubmitted by the Region in mid-1970, and again disapproved by Council. The substance of the cumulative criticism of this proposal related to: 1) the emphases on developing an organization rather than on designing programs geared to improving patient care; 2) lack of data used to identify needs; 3) lack of agreement among university, RMP and project representatives about the role of the extension agent; 4) the absence diasouri RMP , ~24- RM 00009 5/71 of plans for coordination of the educational benefits from other MRMP activities, particularly community-based ones, with the proposed activities of this project; 5) lack of ‘systemmatic evaluation; 6) the size of the request ($2,000,000 over a five year period) and 7) the need for more full-time direction of such a comprehensive activity. Briefly, this proposal would attempt to develop the framework of voluntary participation, interaction and cooperation of continuing education agencies and institutions which are. necessary before a region-wide system of continuing education can be established. Cooperative arrangements would result from three related activities: , 1. A Continuing education inventory would be initiated, with continuous updating, of all continuing education activities provided by institutions in the Missouri subregions. This would identify duplications, overlaps and gaps in overal] educational] programming in the Region. , 2. Teacher-consultant linkages would be developed consisting of a specially assembled cadre of representative health professionals working with Regional counterparts in specific locations, to identify education needs common to each profession. The. consultants will also provide links to the Advisory Committee on Continuing Education ‘ 3, A local educational coordinator in each of five subregions would give individualized assistance to health care institutions in - developing continuing education programs tailored to their own needs. (A sixth subregion will receive this help from central project staff.) These coordinators would be part of Core staff. . Second Year Third Year $142,940 - $256,245 “Fourth Year Fifth Year $225,172 $212,172 Renewal Projects Renewals Project #26R - Training in Arrhythmia and Resuscitation (Community Hospital Nursing Staff) This project would provide two weeks of training at UMMC in monitoring and resuscitation techniques for acute cardiac conditions to community hospital nursing staffs. The course will consist of one week's initial training and a week's advanced training 3-4 months later, utilizing the Rocom Multi-Media Instruction System and observation at the Coronary Care Unit, UMMC. Approximately 100 nurses would be trained per year at the UMMC plus another 50 in community courses. First Year Second Year Third Year — — on art SRD FORT 4 é. Reply to Attn of: Subject: To: _Chief, Grants Management Branch Pye -25- DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE ; HEALTH SERVICES AND MENTAL HEALTH AGMINISTRATION March 8, 1971 Staff Review of the Missouri RMP's Triennial Application, RMO9. Acting Director Regional Medical Programs Service eg fet THROUGH: Chairman of the Month Cry I. Chief, Grants Review Branch, O22 ye dec Fw | 1? oe <- oN Sh Ae ¥ 26 Acting Chief, Regional Development Branches” St Staff met to review the triennial application submitted by the M-R-M-P. A primary purpose of this review was to identify and . discuss issues for the site visit on March 30-31. Since only six projects have conmitment and since any reduction in the level of funding for 1971-72 would conceivably alter the Region's plans for use of committed funds, deliberation of the continu- ation portion of the application seemed of lesser importance. Staff recommended approval of the following continuation request: #46 Hi-Blood $163,419 #50 Joplin Stroke Prevention 87,653 #51 Sikeston Intensive Care 107,796 #52 Health Careers 100,777 #55 Cameo (tumor registry) 114,572 #58 Cardiovascular Education and Evaluation __116,570 $690,787 Staff was gencrally satisfied with the first year's progress of these projects. Representatives from the Continuing Education Branch noted that since the Health Careers proposal no longer falls within RMP policy and since some of the activities have beon undertaken by contact with the AAMC Division of Student Affairs (with @.F.0. funds), the Region might wish to consider reducing or even phasing-out support of this project. Staff wondered whetner the CAMEO project was receiving any technical assistance in computer programing -26- Page 2 - Acting Director, RMPS from the Advanced Technology Proposal (#49). Staff would also like clarification of the statement that the objectives of project #51, Sikeston Intensive Care, are being incorporated into the new proposal, © #77, Cardiac Care Missouri. Staff also recommends approval of the core continuation request of $1,100,000, while recognizing that with the proposed expansion of core by $374,165 for district offices, continuing education staff and activities in Kansas City, the total core request will be a major issue at the site visit. — In addition to the continuation request, the Region's fifth year. budget includes the following: $. 374,165 Core Approved but Unfunded Activities 519,208 Supplemental and Revised Projects . 1,703,690 Renewal Projects 274,112 Developmental Component ‘400,000 $5,061,962 The issues for the site visit are in an attached memo directed to the members of the site visit team. One issue which staff raised requires your specific consideration and guidance. This issue concerms the structure of the Regional Advisory Group and whether the ultimate - decision-making responsibility rests with the entire three-committee group (Liaison Committee, Project Review Committee and Advisory Council) or with the Advisory Council only. A description of the Regional Advisory structure is on page 9 of the attached memo. Our questions are twofold: | 1) Can the entire three-body group constitute the RAG; 2) If not, what would be an acceptable arrangement? With the impending appointment of both VA and CHP representatives (to the Project Review Committee), this question assumes greater urgency. The following staff members attended the meeting on February 25th: Ted C. Moore, Kidney Disease Branch Abraham Ringel, Operations Research and Systems Analysis Branch Cleveland R. Chambliss, Office of Organizational Liaison Cecilia Conrath, Continuing Education and Training Branch Spero Moutsatsos, Planning and Evaluation Teresa Schoen, Grants Review Branch Dan Spain, Regional Development Branch Lee Teets, Grants Management Branch Charles Barnes, Regional Development Branch Dona Houseal, Grants Review Branch -27- Page 3 ~ Acting Director, RMPS Recommendation: Approval of the contiguaton request of $1,790,787 for core and projects #46, 50, 51, 52, 55 and 58. Ma ct tle con \ Dona EF. Houscal Public Health Advisor Crants Review Branch Initials tity Date a | al 7 ec: Dr. Pahl (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971. REVIEW COMMITTEE MISSOURI REGIONAL MEDICAL PROGRAM RM 00009 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: ‘The Committee recommended that this application which requests: 1) an expanded Core, 2) the renewal of two activities, 3) the support of seven Council approved but unfunded activities, 4) the implementation of 16 new projects and 5) a developmental component, be partially supported as follows: $2,450,000 for the 05 year, $2,012,000 for the 06, and $1,825,000 for the 07 year. A comparison of the request and the site visit team and Committee's recommendation for the 05 year is outlined below. Request Site Visit Committee Sequest pite visit wommirres I. Core $1,474,000 $850,000 $850,000 II. Computer and Bisengineering 861,000 . 600,000 250,000 Activities (#69, 71,72,75) III. Community based Activities (#25R, 36,37, 38,39,43,46,50, 51,64,68,73,74,76,77, ; 80,81,83) 1,664,000 _1,000,000 1,000,000 IV. Continuing Educa- tion Activities ~ . (#52,55,58,67,78, 79,82,26R) 663,000 400,000 350,000 Vv. Developmental Component 400,000 -0- -0- ‘TOTAL $5,062,000, 1/ $2,860,000 , $2,450,000 i/ $1.8 million is committed support. af +. Missouri RMP t2e _- , BM 00009 5/71 Critique: In its deliberation the Committee accepted the report of the site visit to the Missouri Region on March 30-31, 1971. The site visit was a comprehensive one, with members of the team reviewing separately the activities in Kansas City, the continuing education program, computer and bioengineering proposals, as well as the central decision- making, review and administration processes in Columbia. Two members of the site visit team participated in the Committee discussion. ” The visitors reported that the Region had made progress in certain aspécts of. program development since the last site visit, but that organizational weaknesses were hampering growth in many areas. The Region's goals are broad, with poorly defined intermediate objectives, Program has been primarily determined by a collection of projects, which have been submitted by interested individuals and aligned with Regional goals after the fact, rather than stimulated on the basis of Regional needs. Program evaluation is geared to assessing the achievement of project objectives, While the Coordinator is well-liked, he is not as forceful or efficient an administrator as he could be. Organized at a time-when RMP's budget was projected for a $200 million level, the Core staff is oriented almost exclusively to projects (processing applications and monitoring approved projects) and has attained ‘a size out of proportion to the program it handles, In addition, Core staff has continued to maintain its adament position that proposals from sponsors in communities outside the University setting be.developed with little staff assistance in order to preserve local flavor and feelings of pride. The team recommended that the size of Core staff be reduced and that better service be offered to local proposers, At the same time, the team encouraged the Region to disengage itself from the project approach to program development by seeking other sources of support, using smaller amounts of Core funds to initiate activities on a short term basis, and phasing out projects which are no longer appropriate or are not performing adequately. . The Missouri RMP Regional Advisory Group has a unique tripartite structure. While it appeared to the site visitors. to work effectively, the decision on the legality of the arrangement, particularly in relation to the placement of VA or CHP representation, seemed more appropriate for General Counsel. Reviewers felt that the very nature of the RAG may have contributed to the.broad and-irrelevant goals. The Regional Advisory Group also appears heavily oriented to project review, rather than to broader regional planning, The review process, which includes technical . consultants and a ranking system, appears adequate, . Relationship with regional resources, particularly providers and voluntary healthagencies, is a strong point in the Missouri program. The visitors were distressed that the Region seems to feel that consumers are adequately involved in program development through CHP representation in the advisory groups. Medical school leadership is. still active in the program, although the proportion of ats ‘Missouri RMP ae 3-5 RM 0009 5/71 University sponsored projects is declining. As the grantee agency, it also provides fiscal and administrative support. The ‘continuing education part of the program seemed in need of a strong director of continuing education on Core staff with an Advisory Committee to serve him. The Coordinator should coordinate efforts of, and offer assistance to, project proposers by locating resources, opening Vines of communication with the medical school and developing models of evaluation, After discussion with project personnel, the team felt such a staff person would prove more effective to the Region than initiation of the Continuing Education Coordination project. The visitors felt that some of the functions of inventory and teacher- consultant activities outlined in this proposal could then be carried out by contract with the UM Extension Division. { With little assistance from Core staff the subregional part of the program has continued to be one of the stronger features of MRMP. The Kans@ City Area Planning Office has hired staff, engaged resources and worked as a coordinator~-facilitator between the new medical school and the rest of the community's health system. The COMPACT proposal, which would coordinate interhospital departmental meetings and upgrade medical education, resulted from these efforts, The site visitors found the concept’ of such a proposal sound and: believed it should be funded by RMP for one year until the participating hospitals assumed its support. Because of the difference in approach to program development and the ° unique problems of the urban setting, the Kansas City Office's relationship with the central MRMP Core in Columbia shows signs of strain, At the present, MRMP's relations with Kansas. City are primarily that of fiscal agent and source of final project review. The site visitors. recommended that priority be placed on staffing proposed subregional districts and strengthening those already in operation. — Both site visitors and Committee members had difficulty determining what course to follow with the computer and bioengineering proposals. Much has been. invested in these activities during the past four years with reports of mixed results from previous site visitors, The present team was pleased with the Region's progress, and recommended reduced support for. one last year, but with the realization that actual marketing and full ‘ implementation of the systems could still be two to three years away. They felt that the operation in Dr. Bass' office in Salem (#72) could prove valuable in determining the practicability of such a module in a solo practitioner's office, although they had reservations about its cost effectiveness. Initiation of the automated patient history system field test in Cape Girardeau was considered an imprudent investment at ‘this time. The site visitors presented their funding recommendations for Committee's consideration. Committee accepted the team's recommendation for a reduction of the Core budget to $850,000 and a reorganization of Cote functions. Implicit in the recommendations is the advice to, 1) preserve and strengthen the district offices, including the Kansas City Office, and the Program Methodology Unit, 2) add a Director of continuing t a ‘ Same Missouri RMP ehn rd, RMOO009 5/71 education to Core staff, and 3) reduce the Planning and Operations staff and consolidate its functions within the Coordinator's Office. Gommittee was disturbed that the Region had not learned to make better use ‘of the Program Methodology Unit, which could serve as a great resource by supplying data bases for determination of Regional needs, That the unit had to sell. the Region on using its services highlighted Committee's continuing concern with MRMP's overall program development and management. Committee deducted $50,000 from the site visitors’ proposed $400,000 level for continuing education activities because they did not believe - that new money for continued support of project #55, CAMEO, should be provided, The development of a computerized treatment logic system for patients with breast cancer and colon cancer raised fears about diffusion and acceptance of the treatment modalities being generated by the system. The $1,000,000 level for community-based projects was accepted by Committee. Although they were pleased that provider support had been successfully brought into MRMP high priority should now be placed on involving consumers in program development. Needs should also be better defined so that such proposals really meet the more pressing health proBlems of the community. Committee was opposed to the site visitors' recommendation of $615,000 for computer and bioengineering activities. While a further year's investment in Dr. Bass' operation ($150,000) was accepted, Committee recommended that support for the other three proposals be phased out this year. $100,000 was provided to phase out these activities. Complete termination reports of the five years activities should be submitted to RMPS. One reviewer raised the question of appropriateness of continued RMP support for computerized EKG development when commercial funds are now available. In addition, he stated, most systems have not progressed to where review by a cardiologist can be totally supplanted by the computer analysis. Reviewers also thought that Missouri's efforts should have been directed to hospitals with larger volumes of EKG's than to individual physicians. There was agreement with the site visitors that the developmental component be denied since neither group believed that the Region had demonstrated it was ready for or would utilize such funding in imaginative ways. . , In conclusion, Committee stated that they thought a site visit in a year's time for assistance, as well as evaluation purposes would prove helpful to the Region. Dr, Mayer was not present during the deliberations of this Region. — RMPS/GRB 4/22/71 . " DEPareT MENT OF HEALTH, EDUCATION, AND WELFARE . “oe PUBLIC HEALTH SERVICE - , : HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION 3... April 12, 1971 “Reply to » Attn of: “Subject: Short. Summary of Missouri RMP Site Visit Findings, March 30-31, 1971. To: Director . Regional Medical Programs Service eS all : wl Through: Acting Deputy Director ek od Regional Medical Programs Service | The ‘site visit team consisted of: G; V. Brindley, Jr., M.D., Chairman Department of General and Thoracic Surgery, Scott and White Clinics, Temple, Texas, and Chairman of the Site Visit. . Alexander M. McPhedran, M.D., Emory University Clinic and Council Mémber. William L. Black, Ph.D., Staff of M.I.T. Lincoln Laboratory Donald F. Brayton, M.D., California RMP Area IV Coordinator Js Francis Dammann, M.D., Professor of Biomedical Engineering, University of Virginia School of Medicine L. PB. Johnson, M.D., Practicing Physician, Rockford, Illinois ny LL. Komaroff, M.D., Beth Israel Hospital, Boston, Massachusetts, : rd L. Thompson, Ph.D. Dean of General Studies Sessions and - Summer Sessions, University: Of Minnesota. Miss Dona Houseal, Grants Review Branch, RMPS n E. Leach, Ph.D., Continuing Education and Training Branch Mr. C. Ray Maddox, DHEW, Region VII. Miss’ Teresa Schoen, Planning and Evaluation Branch Mr. ‘Dan Spain, Regional Development Branch The: purpose of scheduling a site visit for Missouri at this stage in the Region's development was to examine the new MRMP three-year plan-+ -a product. of. its operational experience since 1967 which requests expanded’ funding at a time of reduced overall RMP grant monies. This level of funding would support further program development in the Kansas City District and in smaller regional centers, renewal of several computer/ bioengineering R & D activities,.and a substantial developmental ‘component, Projects presented in this plan can be grouped in four mainclasses: program guidance, community service, continuing education, computer/bioengineering activities. - a view of the-complex character of the Region, the site visit. was divided into four parts. On March 29th, the entire team met in ‘Kansas City for an evening briefing and strategy session. On March the team divided into groups. a ial e Page 2 - Director, «MPS Team I (Dr. Brindley, Dr. Brayton, Miss Houseal and Mr. Maddox). traveled to Columbia to review the region's central decision-making processes, core operations, and relationships with other statewide agencies and institutions. Team II (Drs. Thompson and Leach) accompanied the first team to Columbia and met that afternoon and the following morning with various regional representatives involved with the Region's continuing education activities, Team III (Drs. Dammann, Black and Komaroff) flew to.Salem, Missouri, to review the computer/bioengineering components which had been assembled and field tested in a local physician's office. They also met with the project proposers in Columbia on the following morning, Team IV (Dr. McPhedran, Dr. Johnson, Mr. Spain and Miss Schoen) remained in that area to discuss RMP developments there - particularly relationships with the new medical school and linkages with providers and other health- related agencies, The entire site visit team convened in Columbia on the evening of the 30th for a review of the first day and to discuss changes in strategy. Towards the end of the second day, time was provided for an executive session to discuss overall findings and recommendations and then to provide feedback to the Region before adjournment. While the structure of this site visit was more complex than most, the size and diversity of the Missouri program necessitated a review similar to that conducted at the last visit in October 1969. The site visit team was generally pleased with the Region’ $ progress since that visit but stated that serious organizational weaknesses were hampering growth in many areas, The Region's goals and objectives are vague and broad. They do not seem ‘to have changed much since the beginning of the program, There was not much evidence that the Region had attempted to incorporate HEW or HSMHA objectives or priorities within their own. Program has been primarily determined by a collection of projects, which have been submitted by interested individuals and aligned with Regional goals after the fact, rather than stimlated on the basis of regional needs, Evaluation, then, has become ‘a matter of looking at the achievement of project objectives. The organizational effectiveness of Core was seriously questioned by the site visitors. While Dr, Rikli, the Coordinator, is well liked around the Region, he is not as forceful an administrator as he could be. With so many project activities, a large core staff, his involvement with the Extension Division and other University matters, he is spread so thin that his control of the program suffers. Core staff .itself has several strengths and weaknesses, The strengths. are the Kansas City operation (to be discussed below), the other subregional Page 3 - Director, MPS offices which are engendering provider support at the community level, and the Program Methodology Unit, which could serve as a great resource in building program definition by supplying a data base. The chief weakness is that Core is presently organized around projects - first processing project applications and then monitoring the approved proposals. The site visitors further determined that the number of staff hired to perform these tasks was out of proportion with the total size of the program and should be reduced. A further criticism was that the planning section had not offered enough assistance to project proposers, particularly to those outside the university setting, in project development. Core staff has not vered from last year's adament position that proposals be written withoutCore staff assistance in order to preserve local flavor and feelings of pride. The team, however, thought that better service could be offered to these local proposers without injuring their integrity. In fact, the overall program could benefit from a more aggressive approach to proposer assistance ~ from recommending the deletion of aspects of projects which are not appropriate for RMP support to helping to find other sources of funding. Ina time of lessening availability of funds from the national level, Core's persistence in turning out a large number of projects seemed anachronistic, The site visitors believed that the central Core could profit the Kansas City operation's example of using smaller amounts of Core funds imaginatively to initiate activities on a short term basis until others could support them. Core also seemed to become so committed to funded projects that they rarely modified weak proposals and had difficulty in phasing out those which were not performing adequately. The site visitors felt that it should not take three years to phase out those projects. The Regional Advisory Group also appeared heavily oriented to project review. While data for planning on a Region-wide basis has been collected. by Core staff, there was little evidence that the RAG has used this information to assess need and recommend the initiation of appropriate > program activities. Little thought had been given to the use of the developmental component, other than to stimulate or start up project activity. The Missouri Regional Advisory Group has a unique structure among RMP's. It includes. three bodies-- the Liaison Committee, the Project Review Committee, and the Advisory Council. The membership and the structure are described in the staff summary of the application. Arranged this- way in order to allay fears of University domination of the program, the Regional Advisory Group as a whole performs effectively. The problem: of which group the CHP and VA representative should belong to and the legality of such a ‘structure, particularly when projects disapproved by the Liaison and Project Review Committees are then approved by the Advisory Council, the site visitors believed, should be settled at the General Counsel's level. The review process, which is the responsibility of the RAG, is adequate, It provides for an assessment of the proposal's relation to activities supported by other agencies in the Region, technical review (with occasional site visits) and a determination of its place in the overall e. . Page 4 ~ Director, APS RMP »orogram. ‘Two of the three groups use a numerical rating, although the eriteria on which the rating is based has not been formalized on paper. CHP comment has been instituted, Relationships with the regional resources is a strong point in the - Missouri program, The program seems to have the support of the Medical Society and many practicing physicians, the doctors of osteopathy, nurses, allied health professionals, and hospital administrators.. Voluntary agencies' representatives spoke well of MRMP, as did those from CHP. Although the Region seems to feel that consumers were adequately involved through CHP, they are not generally well involved in program development. Medical school leadership is still active in the program, although the proportion of University-sponsored projects is declining. As the grantee agency, it also provides fiscal and administrative support. Program as stated earlier, is a composite of projects. Two parts of the site visit team reviewed particular parts of the program-continuing education and computer/bioengineering - in great depth. Continuing Education Drs, Thompson and Leach spent a great part of their time discussing the Continuing Education - Coordination Project and the proposed appointment of a Core director of continuing education with the Regional representa-~ tives, The visitors agreed that the inventory and teacher-consultant activities described in the twice disapproved and revised Continuing Education Coordination Project would possibly serve useful functions in identifying continuing education needs of various health professions around the Region. Discussion with directors of ongoing and proposed projects brought the visitors to the realization, however, that what is most needed is a strong director of continuing education on,Core staff, who could coordinate efforts of, and offer assistance to, project proposers by locating resources, opening lines of communication with ‘the medical school and developing models of evaluation, There was significant concern among University-affiliated staff that such a person would not involve MRMP Core in, or sponsor through Core, operational activities, This would, in the opinion of the site visitors, weaken the ability of such a person in assuming a strong role with the Continuing Education Coordination project or with“other projects. The site visit team recommended strongly that the Core Director position be fiinded and that the functions of the Continuing Education Coordination Project be given to the Core Director of Continuing Education. An Advisory Committee named in the proposal should also be selected and serve the Core Director. Core might then contract with the Extension Division for some of the functions outlined in the inventory and teacher-consultant activities. Projects designated by the Region as primarily continuing education- oriented were also reviewed. By and large, they serve the purposes of an individual institution or community, rather than the Region's needs in continuing education or manpower development as expressed in an overall plan. a Page 5 - Director, RMPS . an - - Computer/Bioengineering The visitors who reviewed this part of the program were pleased with the progress since the last visit. The site visitors traveled to Salem to visit the proposal which had assembled and, field tested the computer and bicengineering components in a solo practitioner's office in Salen, Missouri, While Dr. Bass' exceptional interest and enthusiasm were obvious assets, the visitors had reservations about the cost benefit of establishing this comprehensive system in a solo practitioner's office located in such a small community. With the commitment of Dr. Bass, the practicing physician in Salem, the cooperation of the University-based project personnel, the system is operational and being tested in his office on two to three patients a day. The system ineludes the automated patient history acquisition system, automated EKC, biochemical sereening, fact bank and an on~line radiology reporting system. There is still much work to be done with consolidating design, software, and hardware changes, and marketing of the total system may be two or three years away. With a.change in project direction, the automated EKG proposal has overcame many of the obstacles, including reducing the cost per EKG, facing it in the fall of 1969. Several major weaknesses still need to be eorrected before full implementation. Since developments are occuring so rapidly, however, the site visitors recommended looking at these components in another year to determine future funding. The site visit team believed that the Fact Bank should be supported by outside. sources after this year and that the Cape Girardeau experiment not be started at this time. Community-based Programs, including Kansas City After hearing from some physicians. in smaller communities around the state and visiting the Kansas City subregional program, the site visitors concluded that the activities in these areas continue to be some of the more dynamic aspects of the program, The Kansas City Area Planning Office has made great progress since the last site visit---staff has been hired, resources found and program activities initiated. Located in the only major metropolitan area in MRMP, the Kansas City Area Planning Office has seen its role and problems as distinctly different from those of the Region as a whole. In the "Hospital Hill" - section particularly, Kansas City has a considerable concentration of health resources and ongoing activities, including: a developing, eommunity-oriented Medical School, a large number of community and University-affiliated hospitals, developing Model Cities and OEO clinics and health centers, a burgeoning CHP "b" agency, supportive civic leadership and professional societies, a variety of allied health training resources and continuing education programs and a new, non-profit technical assistance organization - the Health Resources Institute, “ Page 6 - Directv. RMPS With such resources available, the KC Area Planning Office has concentrated on a coordinator-facilitator role, particularly focusing on activities related to Medical School development as part of the total community health system (i.e., assisting in establishment of a Community Wide Residency to provide programmed clinical experience for medical students and residents in community hospital, health centers and the KC General Hospital docent units.) Four projects have been developed in the area -- the terminating Programmed Comprehensive Cardiovascular Care Project, the ongoing project Hi Blood, the. proposed Improvement of Pharmaceutical Services and CQMPACT. The Site Visit team considered these to be basically sound concepts and well developed. But despite encouragement from MRMP to channel its efforts into further projects, the Kansas City Office prefers to maintain its current role, which site visitors agreed was an appropriate one. This independence, a probable source of tension within MRMP, nevertheless seems to have been accepted by the Region in view of the area's peculiarly urban problems. Besides general concurrence of Kansas City goals with very broad Regional goals, MRMP's relations with Kansas City are now primarily that of fiscal agent and source of final project review. Conclusions and Funding Recommendations - The site visit team concluded that the Missouri RMP is making progress, particularly in subregional development, which should continue to be fostered. Serious organizational problems, an overwhelming project orientation to the accomplishment of program, and lack of full assistance for those developing proposals at the community level disturbed the site visit team and influenced their determination of funding recommendations. For their next three years, the Region has requested: 05 06 . 07 $5,061,962 $4,310,940 $3,511,564 The fifth year request includes: $1,500,000 for Core 600,000 for continuing education activitics 900,000 for computer and bioengineering proposals 1,700,000 for community-based activities 400,000 for a developmental component $1,800,000 of the $5,100,000 request is committed support. The site visitors. recommended a $2,865,000 level for the 05 year which includes: $850,000 for Core with the strong suggestion that the subregional or district offices, including the Kansas City Office, and the Program Methodology Unit be perserved and strengthened. ‘The Core Director of Page 7 - Director, .MPS Continuing Education should be added to staff. However, it was reccommended that the Planning and Operations staff be reduced and consolidated with the Coordinator's Office. $400, 000 for continuing and new continuing education activities. This amount includes reduced funding for projects #26R, one-year funding for #78, full funding for #79, no funds for #82 and #67 and suggestions for improving and phasing out ongoing activities for which outside support now exists or RMP support is no longer appropriate, $615,000 for one year only for computer and bioengineering proposals. $1,000,000 for community-based projects with advice to the Region to continue to emphasize this vital part of the program. No funds for the developmental component, since the site visitors did not believe the Region has demonstrated that it was ready for or would utilize such funding in imaginative ways. A summary of the three years funding recommendation follows: 05 06 07 $2,865 ,000 $2,067,000 $1,825,000 hot & We vor Pieatdo a Dona Houseal Public Health Advisor Grants Review Branch ° REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) MOUNTAIN STATES (WICHE) REGIONAL MEDICAL PROGRAM RM 00032 5/71 525 West Jefferson April 1971 Review Committee Boise, Idaho 83702 PROGRAM COORDINATOR: Kevin P. Bunnell, Ed.D. This region is currently funded at $1,873,974 direct costs ($365,146 ind.) for its third operational year, ending February 28, 1971. The Anniversary date has been changed to June 1 at the request of: the region, with additional funds ($64,776 ) being required for the 3-month extension, based on the present rate of expenditure. It should be noted that varying indirect costs for the region represent an average indirect rate of 19.5 %, of the total direct cost award, The Triennium application under review is composed of: I. - A Developmental Component II, - The Continuation of Core and 11 ongoing activities III. - Proposals for 6 new projects Iv. - The renewal of 1 activity The region requests $2,449,940 for its fourth year of operation, $2,617,542 for the fifth, and $2,486,328 for the sixth. A chart identi- fying the components for each of the three years is included in this summary. A site visit is scheduled for March 8-9, 1971, and a preliminary staff review of the application has identified several issues for the visiting team's consideration and assessment. These are also a part of this summary. In the general reduction of funding levels for all regions,MS/RMP (WICHE) received a committed direct cost level for FY 1971 of $1,474,765 (from.$1,611,764). FUNDING HISTORY (direct cost only) PLANNING STAGE Grant Year Period Funded 01 11/1/66 - 10/31/67 $698,845 02 11/1/67 - 12/31/68 884 ,034 OPERATIONAL PROGRAM 01 3/1/68 - 2/28/69 (overlaps with planning stagejand 01 (Increase) supports 1 operational activity and 2 months Core 346,159 MOUNTAIN STATES RMP -2- RM 00032 5/71 OPERATIONAL PROGRAMS (cont.) 02 3/1/69 - 2/28/70 - - $1,562,967 03A2 3/1/70 - 2/28/71 1,873,974 HISTORY OF REGIONAL DEVELOPMENT Development of the Mountain States Regional Medical Program was based on an extensive analysis of the area's health needs, and methods to meet those needs were carried out during its planning phase, WICHE (Western Interstate Commission for Higher Education), a compacting organization of 13 western states, had been interested and active in developing medical education programs in the western states that did not have medical schools. The WICHE Advisory Council on Medical Education recommended that the four states be designated as a Region for a Regional Medical Program under P.L. 89-239, and that WICHE apply for a planning grant with objectives of upgrading and improving the existing facilities at community levels to provide optimum patient care in heart disease, cancer and stroke. WICHE received a planning grant from the Division of Regional Medical Programs for a two-year program, beginning November 1, 1966. Within a relatively short time, four full-time and six part-time physicians formed the nucleus of a professional staff. A regional office was opened in Boise, Idaho, to coordinate activities in the four-state area. State field offices were opened in Great Falls and Missoula, Montana; Boise, Idaho; Cheyenne, Wyoming; and Las Vegas and Reno, Nevada. WICHE headquarters office in Boulder, Colorado handles the fiscal management. Preliminary analysis of the surveys made under the auspices of the planning grant indicated a critical need for coronary care training and cancer diagnostic and treatment centers. The establishment of the Missoula Intensive Coronary Care Training Program for physicians and nurses, and the Tumor Institute in Boise, served as first steps in meeting the goal to develop new clinical resources and educational programs. The survey findings also indicated the health professional's desire to increase his capabilities to care for patients and provided the impetus to develop programs focused to meet local needs. The region's first operational site visit took place in February 1968 and its second in October 1968. It was clear that the regional council of State Directors was becoming more effective as an integrating and planning activity. As state programs evolved, a network of subregional offices developed in Las Vegas, Reno, Roise, Pocatello, Cheyenne, Buffalo, Creat Falls and Missoula. The site teams believed that this represented the minimum organization mandatory for continued health planning and the development of further operational programs for the region. MCUNTAIN STATES RMP -3- RM 00032 5/71 GEOGRAPHY AND DEMOGRAPHY The Mountain States (WICHE) Regional Medical Programs includes the four-state area of 435,643 square miles of Wyoming, Nevada, Montana and Idaho with a total population (enumerated in 1970 Census) of 2,230,000 persons, The population in the four states increased about 14% compared with the 1960 Census (and notably Nevada), With the exception of the few larger cities, the rural population represents nearly 50% of the total.. FACILITIES AND RESOURCES In the last few years there has been a shift in resources and facilities with an increase in training facilities and hospital capacity. Nevada has a developing 2-year medical school, with opening scheduled for 1972. The number of active practicing physicians and osteopaths totals 2,100: 647 in Idaho, 696 in Montana, 451 in Nevada and 306 in Wyoming. The ratio of physicians and D.O.'s averages about 94 per 100,000 population ranging from: 89 in Idaho to 102 in Nevada; a catio of 98 for Montana and 94 in Wyoming. The latest data regarding graduate nurses indicates a total of about 9,600 registered nurses. Of these 6,700 (almost 70%) are reportgd to be actively employed in nursing. They are located as follows: Idaho 1,954, Montana 2,483, Nevada 1,060, Wyoming 1,209. “The increas® since 1962 is about 250. The number of schools whith are training allied health staff has increased some. There dre a total of 14 schools of medical technology (all hospital affiliated) in the region with 6 in Idaho, 4 in Montana, 3 in Nevada and 1 in Wyoming. There are 22 sehools which provide training for radiologic technicians: 7 in idaho, 6 in Montana, 7 in Nevada and 2 in Wyoming. Two in Nevada are University based. The region's 15 professional nursing schools, 13 of them college or “university affiliated are: 4 in Idaho, each college affiliated; 6 in Montana, 4 of them college affiliated; 2 University based in Nevada and 3 college affiliated in Wyoming. 30 licensed practical nurse training schools are also operated. Many are school district or college affiliated as fotlows: 15 in Idaho, 5 in Montana, 2 in Wyoming and 8 in Nevada. Community general hospitals have increased in number and in bed capacity, compared with 5 years ago. There are 148 short term non-Federal hospitals with a capacity of 10,496 beds: Idaho has 48 and 2,879 beds; Montana has 56 and 3,841 beds; Nevada has 17 and 1,951 beds and Wyoming 27 with 1,825 beds. There are also 4 long-term special general hospitals with 963 beds and 5 V.A. general hospitals with a total capacity of 826 beds, MOUNTAIN STATES RMP ~4- RM 00032 5/71 REGIONAL ADVISORY GROUP fhe necessity for streamlining the operational structure of MS /RMP promted a regoranization of the RAG, retaining the geographic representa-. tion while reducing the total number of members. Geographic coverage , has been broadened and Task Forces and committees have been increased. The Core staff and the RAG working together developed specific feasible and long-range objectives for the MS/RMP Triennium, Utilizing © questionnaires to each member, critiques and comments were obtained to assist in shaping the final draft, which was presented to the entire Group for consideration and approval. The broad regional objectives established by RAG represents expansion of ongoing activities which are focused on four specific targets: 1) Sub-regional centers for Continuing Education; 2) Health Centers for Residents; 3) Stimulating Health Manpower development; and 4) Specilized Centers Development. A system for setting priorities for activities within these objectives is currently under development. The Mountain States RMP is providing expertise and resource personnel for health planning in each of the four Model Cities within the region. Core as well as RAG representatives have leading roles in each state and area. The present RAG includes two CHP representatives as well as one appointee from the Veterans Administration. REGIONAL GOALS AND OBJECTIVES The region has identified four goals which are expected to be areas of major program emphasis for the next Triennium. These may change in the event of unexpected circumstances, but long-range planning (3 year) reflects the following overall objectives: Sub-regional Centers for Continuing Education - These will be associated with a community hospital and, when possible, an educational institution, have a local Advisory Council consisting of consumers from a variety of health occupations. Continuing health education opportunities, through a sub- -regional faculty of skilled practitioners who are also skilled teacners, will develop a mechanism for continual evaluation of continuing health education needs, These efforts will be coordinated with Public Health Departments, voluntary health groups, hospitals, and other organizations in developing programs, , Health Services for Rural Residents - The region hopes to improve the quality of, and accessibility to, basic health care for citizens of the region, with emphasis on those living in rural areas, This will be accomplished through the use of new types of manpower, new organizational patterns, service-oriented systems, and new equipment. Plans are underway for development of basic health care teams having MOUNTAIN STATES RMP -5- RM 00032 5/71 © an appropriate combination of health occupations, with new kinds of manpower to serve rural areas,e.g.,Medex, medical referral specialists, nurse clinicians, etc. The region is also planning and developing sub-regional health centers, transportation mechanisms for rural 4 patients, demonstrations of use of remote TV for diagnosis and prescription. Educational opportunities for indigenous “health educators" such as health aides, and Indian health advisors, are also being explored. Stimulate Health Manpower Development - MS /RMP hopes to stimulate educational institutions, state systems of higher education, hospitals, and professional associations to plan and develop new programs and improve programs for in-service education. This will be done through the strengthening. and expanding existing programs, and encouraging planning and development of programs for new health careers, Also, attention will be given to the development of basic sciences education and other clinical training for medical education and students of health occupations. In-service education opportunities that will improve careers and facilitate transfer into new careers will be developed. Specialized Centers Development - Through educational programs MS/RMP will assist in development of specialized centers located in selected urban centers. within reasonable access of urban and rural residents as model or demonstrations for diagnosis, consultation and education related to major diseases and disorders. © The WAMI Program (Washington, Alaska, Montana, Idaho) is underway to provide medical education extending beyond the campus of the University of Washington at Seattle to communities of this region in Idaho and Montana. Sub-regional centers with the four states have been identified in twenty strategic areas having a critical mass of population, patients and practitioners. These new centers, now in various stages of implementation, will provide an organizational base for the coordinated activities throughout the region. Idaho has established seven sub-regional centers with part-time Coordinators, each located in communities served by a university or community college. Montana has designated five RMP Districts, with Medical Education Coordinators thus far for Districts one (Western Montana and three (Eastern Montana). A Coordinator for each of the years 1972, '73, '74, is a long-range projection for the remaining three Districts. Nevada has appointed community Coordinators in Elko and Ely, and a third is proposed for Carson City. MS/RMP is working with the Nevada University System in its development of a two-year medical school in Reno. Wyoming is developing Educational Processors (medical educators for ‘smal¥ hospitals) through special seminars. @ : J Rs & & MOUNTAIN STATES RMP -6- RM 00032 5/71 CORE STAFF ACTIVITIES Core staff consists of 34,92 full-time equivalents located in the | regional and four state sub-regional offices, No significant changes in organization or structure have been made during the past grant period. Sub-regional community education coordinators on both a voluntary and a part-time basis were recruited. A full-time person with training in the applied behavioral sciences was employed at the regional office level to coordinate planning and evaluation efforts. The position of Coordinator of Operations Programs was abolished and expanded and these duties were assumed by the Deputy Regional Director. With the emergence of a medical school in Nevada, discussions are expected during the upcoming Triennium to explore an orderly transition leading to an independent Nevada Regional Medical Program, It will probably be affiliated with the University of Nevada, With the upcoming Triennium, Core staff will assume responsibilities for administering Project #5 - The Montana Continuing Education for Health Professionals. This will be a step in systematizing the development of sub-regional centers for continuing education. The facilitation for planning, development, and inter-relatedness of all operational projects will continue to be a Core staff activity, which will provide leadership for activities proposed for the triennium. Other activities will include the development of an explicit priorities system, a refined. reporting system. which is valid and of immediate use in making decisions, to provide continuous recording and monitoring of program impact. Also, the region is thinking of conjoint Core staff and efforts directed toward the development of more refined program objectives in terms of specific individual staff assignments. . Core staff will also be responsible for planning for the use of developmental funds in order to assist in the transition, a heavy emphasis on continuing education to other forms of "systems intervention." MS/RMP will not abandon continuing education efforts, but the strategy of continuing education will aim toward community-based systems changes and improved inter-professional, and inter-organizational effectiveness, There are four active Model Cities in the region and members of the Core staff in the Idaho sub-region have participated in the Planning and Advisory Committees in the development of the Model Cities program in Boise. An educational specialist on Wyoming Core staff is Chairman of the Health Section Advisory Group for a Model Cities program in that state. A staff member of the Montana Division serves on a state-wide coordinating committee for the two Model Cities in that state. MOUNTAIN STATES RMP -7- RM 00032 5/71 THE REVIEW PROCESS The review process of the MS/RMP is closely coordinated with project development. Survey data and inventories of resources within the region are utilized in generating and developing ideas, which are responsive to regional objectives, as well as regional and national priorities. New by-laws have been adapted for an ad hoc Technical Review Panel. These provide critical review by three experts outside the region which are appointed by the Regional Director in consultation with the RAG Chairman. . . While there is no formal mechanism for project review with the CHP agencies, mitual memberships of executive and advisory boards with RMP Core staff provide for an interchange of information. EVALUATION With the employment of a full-time person with training and experience | in applied behavioral science on the Core staff, a systematic program .. evaluation method has been developed, computerized and implemented in December 1970. It includes correlated information from: (1) a ‘ common regs tration form; (2) a multi-dimensional, objective and cae open-ended “analysis and satisfaction" form for participants; (3) stan- dardized faculty and observer information; (4) an attitudinal = — =f assessment of participants; and (5) administrative and other descriptive information. ; A major criterion in the evaluation system is that it must result | in usable, useful and used information for planning and organfzational growth. , Simultaneously, a more extensive system of program evaluation takes place through staff conferences, consultations with RAG members and involvement of grassroots health providers. In addition, each operational project contains a provision for consul- tation on the technical aspect of systematic project evaluation, based on the principle that evaluation, particularly at the regional level, should be an integral part of the initial development of proposals. Work is also underway on the development of standardized methods for evaluation of application of learning in the existing Continuing Education Projects. Two training sessions have been held by MS/RMP Core and operational staff to stress technical aspects of eva§uation and. other working conferences for staff are scheduled. Another poredon of the evaluation activity has been the initiation of several shor Eftgbes into questions of concern to program functioning. oh ‘ 4 MOUNTAIN STATES RMP - 8 = RM 00032 5/71 DEVELOPMENTAL COMPONENT The stated purpose of the request of $71,000 is for "developmental activities to pursue practical goals oriented approaches to.meet © emerging needs and opportunities identified by mission-oriented task forces and MS/RMP staff." The provision of developmental funds will increase the region's capability to improve communication and planning and to study and redefine emerging health needs at the local level. MS/RMP hopes to explore pilot activities in response to community needs, moving with flexibility and coordination into appropriate programs to strengthen existing capabilities to find effective and efficient ways to improve health service. This will also expedite exploratory’ activities while local resources are mobilized for self-support. In recognition of a change in national direction, the MS/RMP is making an effort to meet the newly established priorities. The policy of MS/RMP Regional Advisory Group establishing priorities, and allocating and authorizing funds will continue with the award of developmental funds. ‘The review process for developmental proposals will be the same as for operational projects with proposals submitted quarterly to RAG members to permit critical review of documents prior to regular meetings. Technical review panels will evaluate proposals as to feasibility and potential for implementation. The region is in the process of developing criteria such as those_ used by the Michigan RMP and the Washington/Alaska RMP for reviewing proposals to determine priorities. Areas of concern will include appropriateness, probability of success, workable relationship, evaluation mechanism, contractional arrangements, potential for development, commitment for continuation after RMP funds have expired, and cost-sharing possibilities. The region submits a list of activities which they consider having a potential for developmental funds; (1) a pilot program for intensive infant care unit in selected hospitals; (2) development of Health Maintenance Organizations; (3) stimulation of cooperative arrangements between federal, state and local authorities to improve emergency transportation services; (4) introduction of new patterns of health services; (5) inter-regional cooperation and programs for development of kidney disease control and dialysis centers; (6) development of radiology and laboratory proficiency; (7) study of the feasibility of a three phase program for diabetics. Fourth Year OPERATIONAL PROJECTS Request $148 ,582 Project #2R - Intensive Coronary Care Training - A slight increase in funds is requested for the next (01) period of the Trienniun, MOUNTAIN STATE RMP -~9 = RM 00032 5/71 after which time it is anticipated that the project will be transferred to the University of Montana and Montana State University for continuation. The training center was established at St. Patrick's Hospital in Missoula, Montana and has served as a prototype for the development of similar units and programs in other areas of the region. The project is considered successful, quite popular and has received excellent support of all participating institutions. Accomplishments of the program have made significant impact on this region with improved coronary care becoming available to an increased number of citizens. Management methods have been improved and interest continues high in participating hospitals, This has resulted in excellent cooperation with the University of Washington, the University of Montana, Montana State University School of Nursing and the five regional hospitals providing supervised bed-side experience. In addition to the existing program for training of physicians and _ nurses, two new programs are planned - one in ECG monitoring for anesthiologists and the other affording short preceptorships to provide tutorial experience for practicing physicians. Requested Fourth Year _. $207,172. Project # 3R- Mountain States Tumor Institute - The region is requesting three additional years support or support for the project's third, fourth and fifth periods. The region feels that continuation for another full three years is imperative to fully implement all aspects of the program and to establish its efficacy through appropriately evaluated mechanism of a regional cancer diagnostic and educational center. The Institute, which is a total cancer therapy center, constructed by St. Luke's Hospital in Boise uses a multi-disciplinary approach to patient treatment with an added component of education, It is the first of its kind in the region if not in the entire West. The MSTI, including land, building and equipment, is provided by St. Luke's Hospital, and is a fully incorporated subsidiary of St. Luke's Hospital and Nurse's Training School, The same Board of Directors governs both institutions. In addition, a policy and planning council with delegated responsibilities for MSTI has been established. A Nurse Coordinator was employed on a part-time basis during the 02 grant year, and a full-time Nurse Educator, a dosimetrist and an additional full-time radiotherapist are also requested. Fifth Year: $207,172 Sixth Year: $207,172 MOUNTAIN STATE RMP - 10 - RM 00032 5/71 Requested Fourth Year Project #5 - Montana Continuing Education for lHlealth Professionals - One additional year is requested (fourth period) although three, additional Medical Education Coordinators are to be added over the. next three year period. , Program activities will be expanded by responding to unfilled requests. Twenty-three programs for 18 disciplines are already scheduled through September of 1971, and at least 10 additional programs are in’the planning stage two of which will be for two additional categories of health professionals... Groundwork is being laid to insure the orderly transition of this project to a self-supporting status. Some supporting contributions already are being made by health professional organizations in the region. Project #6 - Rocky Mountain States Cooperative Tumor Registry - One additional year of support is requested with a slight increase in funds largely for personnel for the four state area. This cooperative registry, which is patient-physician oriented, is designed to be of value to the practicing physician in insuring him patient data and systematic follow-up. The registry involves all of the four states,and in addition, the Intermountain and Colorado/Wyoming RMPs. While progress has varied from state to state, three of the four now have functioning Cancer Coordinating Committees. Some hospitals are not participating as yet, but it is expected that the majority will join during the next year. All registries have participated in advisory committee meetings of the Rocky Mountain States Cooperative Tumor Registry and registry secretaries have attended training sessions in Salt Lake City. The means to continue these activities after June 1, 1972 is under active investigation. The Montana State Department of Health is seeking legislative authorization and funds to continue their portion of the program when it terminates. The State Medical Society of Wyoming is actively encouraging its state to continue participation. Project #7 - Continuing Education For Nursing ~ Nevada Requested This project became fully operational July 1, 1970 with Fourth Year the employment of a project director. It will serve as a $91,271 model for the first of a four phase regional approach to develop a cooperative continuing nursing education program for the four states. The four components of the program have common goals, However, the methodology has been modified in each to meet the specific needs of each state and to maximize use of their educational resources. The deans of the four baccalaureate schools of nursing conceived, planned and guided the emergence of this approach to continuing nursing education. They meet annually to assure continuance of its broad concept. tee Fifth Year: $97,500 Sixth Year: $48,250 (6 mos. only) MOUNTAIN STATES RMP - li - RM 00032 5/71 Requested Project #8 - Inhalation Therapy Continuing Education - Fourth Year This project is moving into its second year with a $76,068 slightly reduced request in funds, The program which is devised for the states of Idaho and Nevada has offered courses attended by personnel throughout the region and other parts of the nation. It provides information, training and skills in the most recent advances in pulmonary care through a two-fold program on a regional basis, Faculty and supporting staff are employed on a part-time basis, primarily from local participants. Consulting services are obtained from the Mayo Clinic, the University of Colorado and the University of California at San Francisco for the nurse technician and the physician courses offered. Workshops and seminars have been conducted as well as other training courses for nurses and physicians and inhalation therapists. Pre and Post-tests have been administered to participants in the nurse and technician courses, and in addition, verbal and written critiques from the seminars are obtained from the students, with their recommendations. Fifth Year: $82,402 Requested Project #9 - Cardiac Care Training - Las Vegas, Nevada Fourth Year The program,initiated in November 1970, is based at the $70,737 Sunrise Hospital, Las Vegas, with laboratory sessions offered at the University of Nevada in Las. Vegas. An additional two years support is requested. In addition to the project director, who is a cardiologist, four physicians from the Las Vegas area and one from the University of California in San Diego, serve as faculty. A qualified nurse educator is the primary nurse faculty. In addition, faculty and project staff from other regional coronary care programs have served as consultants to this project as well as sharing of curriculum and teaching informational materials. Three courses for nurses are planned during the upcoming year with 15 to 18 students per course. An accelerated program is anticipated for the 02 year and will include three physician courses. Fifth Year: $63,700 ; Requested Fourth Year Project #10 - Consulting Teams in Rural Areas - Nevada $33,343 This project is requesting limited funds for an additional two years after an experimental period begun early in 1969. Its major purpose is to stimulate interest and increase skills in health professionals in isolated areas. A nucleus of interested, knowledgeable and profigient physicians, nurses and other health professionals in the Reno a¥#ashave been mobilized to serve as a resource panel from which a consut€jng team ts drawn to visit regularly community hospitals. Local participation MOUNTAIN STATES RMP - 12 - RM 00032 5/71 by all health professionals has been almost 100%, with the exception of Carson City and Elko, which have the largest number of health. professionals, with about 50% participation. Reaction and suggestion forms completed by participants early in § the program indicate interest and a high level of satisfaction, These forms were designed primarily to provide feedback to consultants. Bi-monthly consultant visits will continue to be scheduled in all nine communities, and in addition, evening sessions will be scheduled. The continuing nursing education program (Project #7) will provide nursing follow-up between visits. Fifth Year: $18,500 Requested Fourth Year Project #11 - Continuing Education for Nursing - Idaho $89,255 -This project became operational July l, 1970, and is based at the Idaho State University in Pocatello. It is the second phase of a regional approach to develop a cooperative continuing nursing education program for the region. Its development follows the pattern of the Nevada project (Project #7) and the four components have common goals. The project director, based at Idaho State University Department of Nursing also serves as faculty for educational activities in Southeastern Idaho. A second faculty member is serving Northern Idaho based in the Department of Nursing, Lewis and Clark Normal School at Lewiston. A third faculty member will be based at Boise State College and will serve Southwest Idaho. Fifth Year: $96,887 Sixth Year: $108,459 Requested Fourth Year Project #12 - Continuing Education for Intensive Care Personnel- S88 ,827 Southwest Idaho - The request for funds for the next Triennium for this project which was reviewed by the November 1970 National Advisory Council, plus continued contributions from the are hospitals and the Idaho Heart Association will permit expansion of the effort to include more physicians and nurses. The program is inter-regional and inter-agency in character and is an adjunct to the oversubscribed MS/RMP coronary care training program originating in the Missoula, Montana area (Project #2). This program will harmonize with the regional objectives and will be consistent with the training centers, as well as with the plan to develop subregional centers of continuing education. A consortium of our area hospitals (St. Luke's and St. AlphonsuS,Boise; Mercy, Nampa and Caldwell Memorial) was formed and their contribution, plus a substantial amount from the [daho Heart Association, permitted early implementation of the program. It has made a significant impact on Southwest Idaho and Eastern Oregon. Fifth Year: $92,614 Sixth Year: $85,860 MOUNTAIN STATES RMP - 13 - RM 00032 5/71 Requested Project #13 - Continuing Education for Nursing ~- Wyoming Fourth Year This project was approved by the National Advisory Council $77,308 on November of 1970 and became operational January 1, 1971, with the employment of a project director. It is the third phase of a regional program to develop a cooperative continuing nursing education for the region. The University of Wyoming has agreed to continue the project, subject to availability of funds and other resources at the end of the third year as in the previous application. The development follows the pattern of the Nevada proposal (Project #7). Fifth Year: $82,275 Sixth Year: $85,860 Requested Project #15 - Continuing Education for Nursing - Montana Fourth Year This is the fourth and final phase of the continuing $94,820 education for the four states. The development follows as the preceding projects, the pattern of the Nevada program (Project #7). The project will be based at the MontanaState University School of Nursing of Bozeman, with community health facilities sharing responsibilities. A network of seven learning centers will be established with each center serving one or two secondary centers near or at the nurse's place of employment. Montana State University has agreed to assume responsibility for the project after the first three years of operation, subject to the availability of funds and other resources. Fifth Year: $94,521 Sixth Year: $98,407 NEW PROJECTS ( Proposed for periods two and three of the Triennium) During the next Triennium the MS/RMP will be involved in a transitional period during which several projects will phase out, others will be phasing down and/or developing new emphases, The following programs have been designed to achieve a systems change in manner which is viable and feasible at the grassroots level. Project #16 - A Program for Subregional Development of Health Maintenance Organizations. The goal of this proposal is the stimulation of the development of a locally feasible and acceptable organization of portions of the health delivery system in selected communities. The organization will offer: Comprehensive health care for consumer, including preventive programs; ambulatory care services; strengthened linkages into a referral system; development of a specialized center; and a pre- payment mechanism. ‘ MOUNTAIN STATES RMP - 14 - RM 006032 5/71 The proposal is correlated with the accompanying one dealing with - manpower utilization, which will stimulate readiness for HMOs which will be feasible at the local level and commensurate with national and regional goals. The "systems transformation" called for by this program consists of successive community adoptions and refinements of revised organizational patterns for improved delivery in specific communities. Fifth Year: $49,400 Sixth Year: $110,285 Project #17 - Improved Utilization through Expanded Roles of Existing Manpower. The proposal will support extensive development of more effective patterns of manpower utilization in rural communities. It will concurrently support the training of a "middle-level practitioner" category and facilitates their introduction through community based manpower reorganization efforts, Specific activities will include health personnel training and collaborative learning of new styles of working arrangements, Specific designs will be based on individual characteristics of communities and based on involvement of the key health services and health resource personnel. A coordinated planning and administrative mechanism will be maintained at the regional level. Fifth Year: $58,900 Sixth Year: $70,800 Project #18 - Centers for Care of Childhood Disorders - This proposal will attempt to reduce infant mortality and morbidity in the neonatal period and prevent long-term sequelae of birth-associated events for infants in the Mountain States area. This is only one aspect of a comprehensive program of maternal and child health. The program will designate regional centers through evaluation of vital statistical data, geography and transportation factors and medical specialists available. Secondly, centers will be designated to train personnel, Faculty (physicians and nurses) will be recruited and equipment will. be obtained for demonstration teaching. Evaluation will include data,measuring the centers' ability to correct life threatening conditions through the use of trained personnel and special equipment and facilities and overall improvement in neonatal death rates. Fifth Year: $78,000 Sixth Year: $100,000 Project #19 - Extension of Cancer Centers ~ The purposes of this project are identical to Project #3, which established in Boise a regional cancer diagnostic and treamtment resource, (MSTI) which in addition provides intensive and continuous cancer education program for medical, dental and allied health personnel. SOUNTAIN STATES RMP - 15 - RM 00032 5/71 Funds are requested for establishing in a centrally located community in Montana, a similar resource. There are three hospitals and about 40 physicians who provide major medical specialty referral services for eastern Montana. Both cobalt and chemotherapy are available to a limited degree but services are fragmented. The center planned for this will follow the concept of MSTI in Boise. A unified center similar also to MSTI is also planned for Las Vegas, Nevada. There has been much interest and enthusiasm by health interests in the area for such a center. It will serve a community of 300,000 residents, utilizing the MSTI as a prototype. Core staff will assist in planning and development. Fourth Year: $50,000 Fifth Year: $70,000 Project #20 - Preparation of Physicians as Teachers - The proposal calls for the development of new and relevant educational skills for key health practitioners in the new subregional system for continuing education. This will provide key health practitioners--particularly selected physicians with advanced skills in emerging and existing medical and health education opportunities. Preparation of physicians and other health personnel as key teachers in subregional centers will be accomplished through an educational design which: (1) provides for reducing the "knowledge-practice gap"; (2) provides a "renewal" experience to give participants a competence to effect significant community changes in medical care practice: and (3) provide competence to create and sustain an optimal learning environment allowing for increased discipline competence and more productive interdependent behavior directly related to the community's overall health system effectiveness, Fourth Year: $62,441 Fifth Year: $92,800 Project #21 - Laboratory and Radiography Improvement Program - This program will be designed to improve and make more readily available, reliable clinical laboratory and radiography services. This will be very significant in the overall improvement of medical care in rural areas. Subregion committees will be utilized and consist of consumer representatives, as well as all health professionals (including hospital administrators) having an interest in clinical laboratory and radiography performance. The program will utilize local resources to the maximum; and the system will be largely self-supporting. All aspects of the program will be identified with the subregional committee and not with any official agency or professional group. Cooperation of state and local health departments, community hospitals and professional groups, through appropriate official representation 3 MOUNTAIN’ STATES RMP - 16 - - RM 00032 5/71 on the subregional committees, will be emphasized. Code numbers’. will guard the anonymity of laboratories and radiology departments. f t j A well-trained experienced technologist with some teaching methodology will be employed as project director, He will coordinate all continuing education and quality control programs and serve as executive secretary of the overall committee. Each subregion will employ a part-time person (25%) to work with local committees and assist the project director carry out program activities in his own area, , Fourth Year: $40,000 Fifth Year: $50,000 my RMPS/GRB/3/1/71 | REGICN___ MOUNTAIN STATES CYCLE RM 00032 5/71 BREAKOUT OF REQUEST. OA PERIOD (Triennium) SLOENTIPICATION OF i CONTINUING | PREVICUSLY | NEW | iDOMPONENT LACTIVITIES (RENEWAL TAPPR/UNFUN, ‘ACTIVITIES i DIRECT _‘anprrect’ | Toran i : : : ‘ : . | i ' : DEVELOPMENTAL COYPONENT $71,009 —§ 71,000 $823,927 1 § ou. 997 i i fo" i : i CORE $1,159 ,109 11,159,109 233,425; 1,392,524. OR = Coronary Care Training: 1 $148,582 | {148,582 | 25.615 | 174.197 22a" Turon Tnetiture 207 TIA 1207 17) 6A 190 89 HS - CE for Health Prof, "76,177 3 ot i i 76,177 3 -0- 75.177 eke Turar Resisery 1 164,27] ! ‘ i 166,27] | 16,571 182,792 27 2 CR for Mursine (Nevada) 91,271 1 _ . NATL 24,752 VT AF eo Inhalation anv CE. 76.9468 : : oot ; 76,968 1 10,915 LS, oe4 lL Cartize Care Trainine 79,737 } : i : i 70,737 | 13,204 2 041 ' 33,343 ; i 33,343 1 2,359 35,702 69.255. ; 89,255 + 20,613 108. 688 2 88,827 : | 88,827 1 8,882 97,709 ng (ivenine) 77.508! ~~ 7,208 2 32,639 TC} eaF Nursing Voatens) 94,620 | : 1 94,820 $29,883, 124,703 cintenance ‘ ation i h i woe i “-- : --- : wee Roles of \ : ; : i i ng Manpowe ; i --- one ! oe ! woe P18 - Centers for Care of | | ; | owe we CL Shood Disorders mas el ——— : ras #19 - Extension of Cancer | i i ; Centers ! ==5 ocak Lotte ah s22> 720 - Preraration of Phys. | 4 ; | : as Teachers ‘ i : : . === : sa : == ‘ --° #21 - Laboratory & Radiography Inareverent Bresram = : Sit! —— 1 : . i TOTAL ‘$2, 023,186 "£355,754 ' . .' $71,000 $2,449,940 $507,136 ! $9 957,076 : “Ty : : - * First year of Triemntum (3rd year commitment) to be considered as part of renewal. ; , : , ; ! ! : ' t : : ‘ . REGION MOUNTAIN STATES. CYCLE Rw 00932 5/71 BREANCOU? OF REQUEST 05 ’ PERLOD (Iriennivm) TCONTINCING | (PREVIOUSLY i NEW | . | ACTIVITIES RENEWAL APPR/UNFUN, [ACTIVITIES { DIRECT NATRECT. | TOTAL ms 3 { 1 ' 1 ° 7 i : ‘ i ' . i | : : 5 71,000 _'$ 74.000) $ 23,927 8 04,927 i. ; t : i ! | | : ; ' ' . ; . ! 1 Cone °$4,222,583 1-1 .222,583.'_ 248,692 1 1,471,265 i i HOR ; $149,647 i "749,647 26,503 | 176,355 FAR 207.1723 207 172 aE AOD 271572 6S {oo : --- --- | --- { ih ‘ “-- : { --- : “o- i --- 4 83 97,509 _: | 07.590 27,266 : 124,754 3 82.452 | e240 12,525 3 94,938 | #3 63,7990 | i 63.700 : 13,480 _} 77,180 TR 73,500 | ; 78,500: 1,248 19,648 | - o4.f387 | [94,07 24.072 _t 117,859 vi 2 O27 14 62.414 | O28? f 101,875 i Ta wir aP375 0 Ra TL 116,986 75 Ch, 521 po eg sar) 32,500 + 127,021 i _ BO ~~ : y 49,400 i Qa Oo: 7 i 49400 : 58,900. | 98,900. % ; 58,900 Fe 00N | 75,000 | % 75,000 ; 50,007 ¢ 50,000: = 50,000 : ! G2 G41 ‘ G2 441 < \ 62, GG). i i £6,000 i 490,000 ° : 4c, 000 eT i: , : : : i ! | “| ! ; ‘ : : : | | | | ! 3 | ~ : : | | : : | : : i 4 ; : i i ; { ! | ee : : i i l i ' : : | 7~ ; " | . ‘ « * t TOTAL 1,850,082 S356,819 | mot $409, TAT $2,617,542 ‘$515,689 1 rays ‘ -—-5py -~ St - BREAKOUT OF REQUEST 046 PERTOD RM 00032 $/71 A CREIFICATION ; CONTINUING | Y PREVICUSLY jj New , | | |’ ALL YEARS | ALL YEARS | : me eary ! oO frm Aw Tere 7 Ae ORO j 7 : we mm COMPONENT | ACTIVITIES | RENEWAL i APPR, /UNFIN ACTIVITIES | DIRECT + INDIRECT! TOTAL |: DIRECT | TOTAL l Po. | ar | DELTELOD, | | I$. 73,000 STL, 0001S 232,997 § 94,997'$ 913,000 Ig 284,721 i i { { T : 1 : 1 | ; ! t ; $1,276,129 | | | iy 276.129! 254 819 11840, 049! 3 657,873 | 4 Ek FET [oe james wee ee! 298,229 | 350,357 i 1S207,172 : | 207 172) 44.408 271 S77: 621 516 i Bia 7746 --- ! [wwe | ene ieee 76.177. | 76,177! =-- : i | --- | wn- | --- T64,97% | 189 969 ) £8,959 | : | | 48.250 12.632 | 61,882) 237,021 | 32, KAO ‘ --- i i ' i aa- | --- ' --- i wWsR AINn | oy any --- | --- | wer ee th 7 5 a ~-- ! --- | --- -~-- | ST oFAQ | aA San a | TOS. 459 | | | £198,459 23,7068 | 132,165: 294,601 | 359,902 ° ih ! 97.166 } | | t 97,149 9,714 1046, 8&8? 278,607 | 3206 446K #13 A5.869 3 [ B5.860 36.984 1 121,944 265.83 | 848.877 15 90 407 =! i t | oS 404 34,664 | 132.875! 287,748 | BSf 585 He ; | 110,288 | 110,285 % 170,285) 159,685) 150,585 Hy? ; 179,800 | 70,809 % 70,809 129,700 1 129,700 | 215 i i 19,900 j 100,990 * — 109.809, 178,050 178,900 | vye ; i [70,000 | 70,059 * \ 70,00). 120,000 129,000; a : 92,800 | 92, 800 * 92,800: 155,24) | 155,24) | 2) ; i 50,000 | 50,000 * i 0,000: 90,009 | 90,000! . 1 t . yt ! : i ! i ij i | | 1 | i i i | ! we | | / | ¢ i ' i i ( ' T ! t ‘ | 1 ' y ' t | ! | | | ' | 1 | | | ' i i ; i j t : 1 : ! : ! i | : { { | i | i ! i i : : 7 li ! 2 | | | | : | | i TOTAL | $1,714,271 | $297,172) | $564, 885 97 »486,228 $470,748 $2,957,076 , $7,553,810 | $9,047,382 + Endivess e | | be | nl | ! AneLrecs costs are not OStivatod oe this tims | fo ary { i rnnintenene «| (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE ce MOUNTAIN STATES REGIONAL MEDICAL PROGRAM RM 00032 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: The Committee recommends approval of triennial funding to include the developmental component at the following direct cost levels; Year Request Recommended 04 $2,449 ,940 $1,741,000 05 2,617,542 1,511,000 06 2,486 5328 _1,366,000 Total $7,553,810 $4,618,000 No renal activities were proposed, CRITIQUE: Two members of the site visit team presented findings from the March 8-9 site visit which was held in Boise, Idaho and Reno, Nevada. The Boise portion of the visit was devoted to study of the organization, progress, and future plans for the Mountain States RMP as a whole, while the Reno portion of the visit was concentrated on plans for a proposed Nevada RMP, separate from the Mountain States Program, : The team learned that the RMP has developed an effective network for health planning in the four-state area, Several of the operational projects have been outstanding in promoting better patient care services. The Regional Director has successfully recruited and retained excellent Core staffs. : ~~, Subregionalization has been effected through the establishment of the four-state office, while the regional headquarters at Boise has been instrumental in seeding effective program activities throughout the Region. ‘The RAG has been reorganized from an original group of 160, to a more manageable and effective number of 26, However, the present membership is too heavily wéighted toward physicians; the RAG needs to be broadened with Allied Health and consumer representatives. Both the RAG and the State groupings of practicing physicians and nurses, °* community hospitals, voluntary and official health agencies appear to be well versed on the needs for priority setting and decision making. Core staff has been instrumental in initiating a number of community activities in priority areas, The team felt the Region is able to accept responsibility for developmental funding. The team also reported that tha move toward separate RMP. status by Nevada appeared to be very amicable. Both WICHE, the grantee MOUNTAIN STATES RMP ~2= RM 00032 5/71 organization, and the Mountain States staff appear ready to assist Nevada in its next steps; the RMP has been a positive resource in the development of the new medical school in Nevada, The separation issue will be fully explored in the next year. The reviewers agreed with the site team's recommendation that a dialogue begin with all - dnterested parties--representatives from Boise, Boulder, Reno and | the RAG--to explore means of accomplishing mutually acceptable solutions to all issues involved with autonomy for Nevada as a separate RMP. The Committee concurred with the site visitors’ recommendations regarding the approval of developmental component funding and three- year support for the Region. The Committee noted that the continuing education programs in the four states need better coordination and that RMP support for the Mountain States Tumor Institute should be limited to two more years. The Region should also be advised to broaden its RAG membership. RMPS /GRB/4/26/71 DEPA.. [MENT OF HEALTH, EDUCATION, AND ./ELFARE - . PUBLIC HEALTH SERVICE . HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION March 16, 1971 Mountain States (WICHE) Site Visit Harold Margulies, M.D. Acting Director Regional Medical Programs Service Through: Sarah J, Silsbee Chief Grants Review Branch This is a "mini" site visit report to give you a very general and condensed impression of the region's present status. The team was composed of the following members; Clark H. Millikan, M.D., Chairman Henry Lemon, M.D. Willard A, Wright, M.D. Miss Dorothy E. Anderson, R.N. Herbert B, Pahl, Ph.D. Jessie F, Salazar Miss Elsa J, Nelson Rodney Mercker Richard F. Clanton, JR. Daniel P, Webster The first day, March 8, was spent in Boise, with all four state offices and the regional Core staff and WICHE represented by Dr. Kevin Bunnell, from WICHE, who is the Coordinator, and Mr. John Staley, the Fiscal Management Officer. Dr. Popma serves as Regional Director, Dr. Bunnell discussed the relationship of the MS/RMP to WICHE, which is the grantee organization, WICHE has provided the cohesiveness and sound fiscal management to the region, and in addition, filled the role of "center of excellence" which did not exist. in any of the four states prior to RMP. While the WICHE Commission (39 members) has overall power to criticize, and even reject, program suggestions, there is no evidence that there has been any conflict produced by this authority. The RAG has been reorganized, from an original group numbering about 160, to a more manageable and effective size. The Group needs strengthening tc include a representative of a labor union, minority group or someone who would be considered an "average" consumer, The new Chairman is Executive Director of Wyoming Blue Cross-Blue Shield. te Page 2 « Dr. Me.gulies Sub-regional development is progressing. An example of this is the Montana and Educational Foundation which was funded by Project #5, July 1, 1969, The Foundation has a Board of 13 members which has produced 81 separate educational programs, attended by 3,600 individuals. Currently the Board is reviewing priorities of this organization; looking at problems related to the need for health manpower development and how this might be expedited, They may explore prospects of becoming more active in the development of HMOs. Dr. Grizzle (Wyoming) reported that through MS/RMP's efforts in sub-regionalization, a new record system was developed at the Big Horn Hospital which is now being extended to other hospitals in the area, Also, the University of Wyoming has now taken over the responsibility for the communication network originally developed by RMP. The Mountain States Tumor Institute in Boise treated 770 patients last year, and the estimate is for about 1500 patients for Idaho alone in the current year. The team made some suggestions to be re- layed to St. Luke's Hospital Board of Trustees for diversifying its funding sources, The site team visited the new facility which will soon be ready for occupancy. MS/RMP has wisely concentrated on objectives via their projects which were capable of accomplishment and have led to formation of "contact points" throughout the four States, They should probably now direct their attention to the design of other programs which may be introduced into the already established system. The site visit team addressed the question of administrative methods for priority setting and decision making in terms of program content, budgetary considerations, etc, The team learned that an Executive Committee, werking with the RAG will work out recom- mendations for budget cuts, and each State sub-region will also develop its recommendations, The two sets of recommendations will be negotiated into one list which will be reviewed by the Executive Committee, If necessary, it will be considered by each sub-region again, and thence to the RAG for final action. The team was assured that MS/RMP fully understands that the RAG carries the responsibility for the important concept of priority setting and decision-making, Also, practicing physicians and organized medicine, community hospitals, voluntary and official health agencies are playing a significant role in the four-state program. Participation and involvement of nursing professionals is extensive. There is ample evidence that Core activities have resulted in action-oriented planning, particularly in local level community organization and - planning, i.e., CHP and Model Cities. Page 3 - Dr. Ma.gulies The second day (March 9) was spent in Reno, at the University of Nevada, To quote Dr. Millikan, if there had been a big bonfire going (for separation), it had been dampened considerably before the confrontation with the visiting team. Dr. George Smith, Dean of the School of Medical Sciences, was Chairman, Although. Dr. Smith delineated about eight reasons for Nevada's wish to become an autonomous RMP, there was no real description on his part, or others who spoke for the Nevada group, of what would be done differently Af they were independently organized. The Nevada group appears to be quite far away from the development of a concept of the necessary organizational structure, objectives, etc., in terms of local capability. In other words, there was -conclusive evidence that planning has: not proceeded very far, The presentation in Reno was a most interesting description of educational opportunities in Nevada, both at an undergraduate level and the new two-year medical school. BUT, there was no definition of the roles to be played by the "Nevada Regional Medical Program," Doctor Fred M, Anderson, Member of the Board of Regents, University of Nevada and Commissioner from Nevada to WICHE, as well as Member of the Nevada Section of MS/RMP RAG, reported that statewide elements favor autonomy as soon as feasible for Nevada, He. suggested as one possiblity, an affiliation agreement with WICHE on an interim basis to. benefit from WICHE's expertise in planning, while Nevada continues to plan for full autonomy with the University as the grantee, Doctor Pahl discussed briefly the "transition scheduling", in terms of a target date for separation and referred to timing factors in line with. preparation of new applications, review cycles, etc. The suggestion was made that perhaps a small group which would be representative of WICHE, MS/RMP and Nevada could meet to work out:a plan of procedure, which, in turn could be presented for National Advisory Council consideration and advice. Dr. Millikan pointed out that the split in South Dakota and Nebraska was not viewed by RMPS and the N.A.C. as a precedent upon which Nevada (or any other region) could build its case for secession. Each is a distinct phenomena and with many differences. readily apparent. He was complimentary to the Nevada and to the MS/RMP representatives in its desire for orderly procedures in steps to establish autonomy, He emphasized the need for an organizational matrix to stimulate staff inter-relationships and provide the environment for a series of dialogues, This should include, of course, identification of the requirements of WICHE and give due consideration to needs of all four states, Doctor Bunnell, in stating WICHE's position in the Nevada separa- ' tion expressed the opinion that all of the points raised by Nevada “are resolvable, but, mutually beneficial resolutions will have to be negotiated with representatives of Reno, Boise and Boulder, Results must be beneficial to all concerned. Page 4 - Dr. Marg ies . - : The team discussed very briefly the effect of the cut in funds to the overall program, but did not specifically pin down items for such cuts. Doctors Popma and Gerdes listed a number of areas where ‘reductions would not result in appreciable damage to the program. The region has exhibited expert know how in developing an effective network for health planning in this large four state area,. The Regional Director has been successful in recruiting and retaining an excellent Core staff. The site visitors noted that sub-regionaliza- tion through the establishment of four state offices, plus the regional headquarters office in Boise entails considerable expense. There was agreement, however, that this cost is justified when one considers the significant impact of this means of distributing RMP activities to many communities of varying size throughout the four . States, The consultants recommended approval of the Developmental Component in an amount to be commensurate with pending overall budget negotiations, . Ne ho 7s ‘ ~ ? fessie F, Salazar Public Health Advisor Grants Review. Branch A Privileged Communication RM 00032 SITE VISIT REPORT MOUNTAIN STATES REGIONAL MEDICAL PROGRAMS March 8-9, 1971 SITE VISITORS Clark H. Millikan, M.D., Chairman, Consultant in Neurology, Mayo Clinic, Rochester, Minnesota, Member, National Advisory Council Henry M. Lemon, M.D., Professor of Medicine, Nebraska Medical School, University of Nebraska, Omaha, Nebraska, Member, Review Committee CONSULTANTS Willard A. Wright, M.D., Director, North Dakota RMP, Crand Forks, North Dakota ; Dorothy E. Anderson, R.N., M.P.H., Assistant Coordinator, Community Programs, California RMP Area V, Alhambra, California REGIONAL MEDICAL: PROGRAMS SERVICE STAFF Herbert B. Pahl, Ph.D., Acting Deputy Director, RMPS Jessie F. Salazar, Public Health Advisory, Grants Review Branch Elsa J. Nelson, Specialist for Program Development, Continuing Education and Training Branch Rodney Mercker, Grants Management Officer, Grants Management Branch . Richard F. Clanton, Jr., Operations Officer, Regional Development Branch Daniel P. Webster, Regional Office Representative, Region VIII MOUNTAIN STATES REGIONAL MEDICAL PROGRAM STAFF Alfred M. Popma, M.D., Regional Director, Boise, Idaho John W. Gerdes, Ph.D., Deputy Director, Boise, Idaho Kevin P. Bunnell, Ed.D., Coordinator, Boulder, Colorado Laura C. Larson, R.N., M.A., Coordinator of Nursing and Allied Health, Boise Charles E. Smith, Ph.D., Coordinator Planning and Development, Boise Mrs. Helen Thomson, Coorinator of Information, Boise, Idaho Fred O. Graeber, M.D., Director, Idaho Subregion, Boise, Idaho Sidney C. Pratt, M.D., Director, Montana Subregion, Great Falls, Montana Joseph B. Deisher, M.D., Director, Nevada Subregion, Reno, Nevada Claude O. Grizzle, M.D., Director, Wyoming, Subregion, Cheyenne, Wyoming Donald Erickson, M.A., Educational Specialist, Wyoming Subregion, Cheyenne Mrs. Helen Alexander, Assistant Director for Administration, Montana Subregion, Great Falls, Montana Louise Alcott, R.N., Assistant Director for Administration, Nevada Subregion, Reno, Nevada . Wilma Frederickson, Staff Associate, Nevada Subregion, Reno, Nevada Bette Jean Tranum, Administrative Secretary, Boise, Idaho John Staley, Administrative Services Officer, Boulder, Colorado MOUNTAIN STATES RMP -2- RM 00032 REGIONAL ADVISORY GROUP Arthur R. Abbey, Chairman, RAG; Executive Director, Wyoming Blue Cross/ Blue Shield; Cheyenne, Wyoming Laura O, Walker, Ph.D., Vice-Chairmn, RAG, Head, School of Nursing, Montana State University; Bozeman, Montana Charles A. Terhune, M.D., Immediate Past Chairman & current member, RAG; , Practicing Physician, Burley, Idaho WICHE COMMISSIONERS Dermont.Melick, M.D., Chairman, WICHE Commission Regional Programs; Coordinator, Arizonza RMP; Professor of Surgery, Arizona College of Medicine; Tucson, Arizona Thomas Tucker, Ed.D., WICHE Commissioner: Chairman, Department of School Administration & Supervision, University of Nevada; Reno, Nevada Juanita White, Ph.D., WICHE Commissioner; Nevada State Representative; Boulder City, Nevada Fred M. Anderson, M.D., WICHE Commissioner; Practicing Surgeon; Board Regents, University of Nevada; Reno, Nevada OTHERS Loryn A. Kopan, Administrator, Veterans Administration Center; Ex officio Member, Regional Advisory Group; Boise, Idaho E, E. Gilbertson, Administrator, St. Lukes's Hospital; Boise, Idaho Maurice M. Burkholder, M.D., Practicing Physician; Boise, Idaho Ronald Koons, M.D., Head, Radiation Therapy, Mountain States Tumor Institute, St. Luke's Hospital; Boise, Idaho . Ray Cottner, Assistant Administrator, St. Luke's Hospital; Boise, Idaho Shirlee Koons, R.N., Nurse Coordinator, Mountain States Tumor Institute St. Luke's Hospital; Boise, Idaho , Marie Crisp, R.N., Chief Technologist, Mountain States Tumor Institute Boise, Idaho George Baker, M.D., Member, Core Committee for Mountain States Tumor Institute, Practicing Physician; Boise, Idaho Glenn Talboy, M.D., Member, Core Committee for Mountain States Tumor Institute; Practicing Surgeon; Boise, Idaho Verne Reynolds, M.D., Member, Core Committee for Mountain States Tumor Institute: Practicing Gynecologist; Boise, Idaho Alfred Stone, M.D., Member, Core Committee for Mountain States Tumor Institute; Chief, Department of Radiology, St. Luke's Hospital; Boise John Edwards, M.D., Practicing Physician; Idaho State Representative; Council, Idaho Kay Ortman, R.N., Recent Graduate, Stanford University Nurse Clinician Training Program; Cambridge, Idaho Ethelda Thelen, R.N., Program Coordinator, Continuing Education for Nursing Nevada; Reno, Nevada George Smith, M.D., Practicing Physician; Dean, Medical School, University of Nevada; Reno, Nevada MOUNTAIN STATES RMP -3- RM 00032 OTHERS (cont.) ‘ Thomas S, White, M.D., Practicing Physician; Member Regional Advisory Group; Boulder City, Nevada Richard Licata, Ph.D., Professor of Anatomy, University of Nevada; Member Regional Advisory Group; Reno, Nevada Marjorie J. Elmore, Ed.D., Head, Orvis School of Nursing, University of Nevada; Member Regional Advisory Group; Reno, Nevada Dean Fletcher, Ph.D., Professor of Cancer Research, University of Nevada; Reno, Nevada David Brandsness, Administrator, Sunrise Hospital; Member Regional Advisory Group; Las Vegas, Nevada Hugh Collett, M.D., Practicing Physician; Elko Nevada N. Edd Miller, Ph.D., President, University of Nevada; Reno, Nevada Verlyn Elliott, M.D. President, Nevada Medical Society; Fallon, Nevada Mountain States Site Visit Report -4- RM 00032 . INTRODUCTION: The first day of the site visit was spent in Boise, with ali four-state offices and the Regional Core Staff and WICHE represented. Dr. Kevin Bunnell discussed the relationship of the Mountain States Regional Medical Program to WICHE, the grantee organization. WICHE has obviously provided the cchesiveness and sound fiscal management to the region, and in addition, filled the role of “center of excellence" which did not exist in any of the four states prior to RMP. REGIONAL ADVISORY GROUP: The RAG has been reorganized, from an original group of about 160, to a more manageable and effective number of 26. The site team felt that this is a much more realistic and workable group, and in accord with the previous site visit recommendations. However, the team found the Group to be largely weighted with medical people and generally inadequate in allied health and consumer interests. There was almost —. unanimous agreement that the Group will be strengthened and enriched by including representatives of labor, minorities or other. "average" consumers. The new RAG Chairman is Executive Director of Wyoming Blue Cross-Blue Shield. The recently inaugurated review procedures developed for the RAG seem to be quite comprehensive and workable. These should benefit also by greater input from the broadening of membership referred to above. GOALS, OBJECTIVES AND PRIORITIES: There was neatly uniform agreement from the site visitors that the goal of improving the health care of the largely rural residents of the four~-state area was the most over-riding of the four that are stated, The goals of manpower development and health center development appear subordinate to these. The region seems to have very adequately assessed its needs, problems and resources; objectives and goals are congruent with national priorities. To some extent, funding of operational programs to date appear to have been developed with political considerations in mind to give each one of the states some share in activity, This seemed to the team an entirely reasonable and necessary consideration. - ORGANIZATIONAL EFFECTIVENESS: Dr. Popma, the Regional Director, has served in an outstanding manner as a result of his broad: experience and involvement with Regional Medical Programs on a national.level, and his keen sense of the qualifications required by his organization. The team agreed that the Core staff, which reflects a broad range of professional and management competence in all areas is highly effective. Noted particularly was the management and fiscal responsibility; which falls under the purview of WICHE. One of the strongest features of the MS/RMP organization, is the sub-regional activity, which seems to be proceeding well, especially in Wyoming, Montana and Idaho. Nevada was considered: to be somewhat less well developed in this regard, possibly due to its greater distance and isolation. While sub-regionalization appears expensive, it has proved important in maintaining liaison throughout the four-state area, and as a framework for future development in improved patterns of medical care. The grantee organization (WICHE) traditionally embodies an even larger number of western states for educational purposes, which has strengthened this aspect Mountain States Site Visit Report -5- RM 00032 of MS/RMP. The site team was unable to determine the real extent of relationships with Comprehensive Health Planning on either the A or B levels. Indeed, the team did not glean any positive impressions of CHP activities in any of the four states. Regional resources are well utilized in all four states, There was feeling, however, that lacking is an involvement in non-government and private industrial interests, i.e., the copper companies in Montana and the Boise-Cascade Corporation in Boise. These might prove to be an excellent source of lay individuals, who can serve an effective role in health planning. Practicing physicians and organized medicine are significantly supporting and participating in the program. Many community hospitals, including their boards and staffs are firmly committed and involved. The involvement of nursing professionals is extensive. In general, there seems to be ‘satisfactory political and economic interaction in the MS/RMP. One inter- esting development is WAMI, a program emanating from the University of Washington School of Medicine, aimed at increasing the output of physicians by getting peripheral educational and community health facilities personnel involved in the training of doctors, Idaho and Montana are actively involved in this plan. ASSESSMENT OF NEEDS, PROBLEMS ,AND RESOURCES: The site team felt that these have’ been adequate in most respects, but planning appears to have been limited to the immediate future. For instance, in the Mountain States Tumor Institute program, (based in St. Luke's Hospital), it was clear that planning has thus far been rather limited in scope, that the full scientific potential of the enterprise has not been planned for, and as yet no formal linkage to a state college unit has been developed. This would provide the avenue for educational funding, which will be needed to make the Institute a real community asset. It was suggested that an exploration of an affiliation with the Boise State College might lead to development of a School of Allied Health based at St. Luke's and St. Alphonso Hospitals. The team also recommended that the Board of St. Luke's consider the development of a Scientific Advisory Committee, with thought given to planning for other medical disciplines. It was noted that there is a very excellent surgeon engaged in a large volume of angiography in Boise, and also that 75% of the 150 practicing physicians in Boise are spectalists. In time, the Mountain States Tumor Institute could become a multicategorical health resource. The team also suggested that cancer center planning grant, or other federal support, should be explored with the National Cancer Institute. PROGRAM ACCOMPLISHMENTS: Outstanding is the impressive coronary care training program in the Montana area, and the nucleus of an excellent cancer care activity in the Mountain States Tumor Institute in Boise. Further, RMP outreach to selected communities in developing the nurse practitioner program through a realistic method of obtaining individuals who can contribute to local health care is representative. Also, there is evidence of adequate surveillance of ongoing activities via the sub-regionalization network. This shows great promise for future Mountain States Site Visit Report -6- RM 00032 development, particularly in rural health care if the Core staff sub- regionalization organization is preserved, The nurse practitioner program will need to develop its own training program in view of the discontinuance of Stanford's. The visitors believed that operational programs developed in this region have faithfully reflected the region's initial objectives of improving postgraduate educational availability for practitioners by bringing the program to medical and nursing practitioners. Missing, as far as could be determined by the team, is dental or allied health training on a continuing basis. These efforts have been intermittent. The postgraduate educational activities appear to be quite diverse and fragmented. throughout the states, and rather loosely coordinated . by the regional office. These programs have been expensive in terms of travel funds and consultant fees. However, evaluation of the impact of some of these activities, particularly the coronary care program, has indicated positive results. This has been particularly notable in small community hospitals in influencing physicians 'and nurses coronary care procedures. The MS/RMP realizes that it is now moving beyond the phase of postgraduate training and is beginning to think about the generation of new manpower. The region is faced by the necessity for major cuts in the approximately $800,000 of the continuing education request. While such programs have strengthened the image of Regional Medical Programs throughout the four states,they have also been an excellent proving ground to many health _ professionals in the four states for what can be accomplished through future cooperative efforts. There was concern on the part of the site visitors that in planning for present and future operational activities, Stroke has almost been com- pletely by-passed, The team expressed the hope that in due course this omission can be alleviated. The expanded Mountain States Tumor Institute facility, already referred to above, will be in operation later this year. The planning for this facility has been excellent and includes prospects for ten stories to be constructed atop the present basement level unit. The MSTI is seeking the services of a radiotherapist, a chemotherapist, a physicist, a social worker and technicians. The Institute is beginning to break even in terms of fees and grant funds, In 1970 there were 300 new radiotherapy cases, 400 chemotherapy patients and 70 old cases, all of whom paid fees. The new patient load that is anticipated with the opening of the new facility is 700. The hospital board's failure to think in somewhat broader terms of a future, multicategorical facility has already been referred to under Assessment of Needs, Problems and Resources. The site team emphasized that the hospital board should think about developing a Scientific Advisory Committee which could, in turn, broaden the horizon for the Institute and develop into a major health resource, not only in cancer, but in cardiovascular and neurological diseases as well. Mountain States Site Visit Report =7- RM 00032 The influence of Regional Medical Program activities is quite evident in the Nevada area, largely due to the interest of the Reno physicians and the development of the new medical school. This is most apparent in planning for the training activities of the school. The team was interested to hear from the Deputy-Director that he viewed the lack of a medical school in the region as one thing that has influenced the emergence of interaction of local talent in a manner that might not have evolved if medical school leadership had been available. The Montana Medical and Educational Foundation (Project #5) was funded July 1, 1969, It is directed by a Board of thirteen members which has produced 81 separate educational programs, attended by 3,600 individuals. The concept provides a multidisciplinary approach to continuing education for all health professionals. With funds expiring in March 1972, the RAG is now studying ways and means of attracting other resources, perhaps by providing some service as well as educational functions, Long-range plans for the program, which now crosses state lines into Idaho, Montana, Wyoming and North Dakota . Eventually it will move into existing or future university systems. Also under consideration is the prospect of becoming more active in the development of HMOs. The site visitors were interested to learn that the University of Wyoming has now taken over the responsibility for the communication network originally developed by RMP. Also, through RMP impetus, a new record system was adopted in the Big Horn Hospital which is being extended to other hospitals in the area. The site team was interested to learn about the development of the Nurse Physician Assistant Program. The first registered nurse to be trained will practice in the Cambridge, Idaho community which is presently served by two physicians and covers a radius of 200 miles. The Nurses Association was active in developing the legal instrument--the Nurses Practice Act-- which was spearheaded by Doctor John Edwards, a member of the Idaho State Legislature. Out of 66 physicians contacted personally, and 132 physicians (from a total of 198) who returned the questionnaire, 10 expressed the desire to have a Registered Nurse Assistant. Although this would appear to be a low figure, the team felt that acceptance of the concept in this area is more significant. Nurses are really doing patient work with only somewhat dis- tant supervision. Also, it was noted that liability insurance covering practice activities for participating physicians is continuing without an apparent increase or mark-up in premiums. Planning discussions are underway with the University of Washington leading to participation by Idaho and Montana in WAMT(Washington- Alaska-Montana-Ttdaho). This experimental program proposes regionalization through training by the University of Washington School of Medicine of medical students, interns and residents in the Mountain States Site Visit Report -8- RM 00032 states of Alaska, Montana and Idaho. Communities will be chosen by the University of Washington, based on existing local resources and manpower. In the state of Idaho a series of seminars involving the Medical Association, CHP, the Advisory Committee to the State Board of Education, RMP and others, is seeking the means for establishing an administrative base to relate to. WAMI e t ‘ EVALUATION . \ While the application did not give specific details about Evaluation methods, the team was unanimous in the impression that, under very capable direction, evaluation for the program is of very high quality. The results thus far have been project, rather than program oriented. Also, the team recommended that the assessment of the overall program would be strengthened by in- creased participation of consumer groups and allied health representatives. Since the evaluation mechanism is quite new, there was not, as yet, evi- dence of a strong feedback method to relate program and project evaluation to the Regional Advisory.Group. It was agreed, however, that this will doubtless be a very real part of the upcoming reappraisal of use of reduced funds in the forthcoming Triennium, The data presented to the site team is comprehensive and indicates practical applications and accomplishments in a short period of time, The feedback for improvement in programming is receiving attention. There is in operation now a computer print~out, a common registration form, a quick response scheme, a satisfactory questionnaire, etc. WICHE AS THE GRANTEE In addressing the question, "WICHE--What is it?", Doctor Bunnell explained the functions of the three programming divisions of WICHE: (1) planning and management systems, (2) mental health, and. (3) general “regional” programs such as Regional Medical Programs, student exchange, etc. WICHE as the "backdrop" for the Mountain States RMP seems to be a reasonable and functional organization; mainly because WICHE was already regional in concept. It was organized to serve an educational function, and through the Faulkner Report, had identified the need for a ‘regional’ medical school. Finally, it provides strong management expertise, WICHE is committed to the sponsorship of a strong Regional Medical Program and provides the MS/RMP with an amicable, historical and mutually beneficial background for program goals, Doctor Bunnell responded to the question of the future role of VICHE in Regional Medical Programs with a statement concerning new thrusts for RMP away from Continuing Education to new roles, such as development of Health Maintenance Organizations. Mountain States Site Visit Report -~9- RM 00032 NEVADA AS A SEPARATE REGIONAL MEDICAL PROGRAM: This portion of the site visit took place in Reno, the location of the new School of Medical Sciences, University of Nevada. The site team had previously identified several concerns about the request from Nevada for separation. These were discussed in a friendly and responsive manner. Doctor George Smith, Dean, outlined about eight reasons for Nevada's wish to become an autonomous RMP: Nevada feels it is capable of assuming its own leadership role; they need the authority to assume better local control; an independent Nevada RMP would decrease intermediate levels of bureaucracy (Washington-Boulder-Boise-Reno) ; better utilization of their own facilities and personnel would be possible; more effective coordination of overlapping Regional Medical Programs activities (Intermountain, Mountain States, Davis, Loma Linda) would be possible; development of local priorities would be enhanced; as would the development of new relationships with WICHE. The last point was considered somewhat irrelevant to the issue of a separate Regional Medical Program for Nevada. Indeed, there was no real description on the part of spokesmen for the Nevada group of what would be done differently if they were independently organized, The Nevada group appears to be a long way from the development of a concept of the necessary organizational structure, objectives, etc., in terms of local capability. The presentation was a most interesting description of edu- cational opportunities in Nevada, both at an undergraduate level and the new two-year medical school. However, there was conclusive evidence that planning for a new Regional Medical Program has not proceeded very far. Neither was there a definition of its role in the new School of Medical Sciences. Doctor Fred M. Anderson, member of the Board of Regents, University of Nevada and Commissioner from Nevada to WICHE, as well as Member of the Nevada Section of MS/RMP RAG, reported that statewide elements favor autonomy as soon as feasible. He suggested as one possibility, an affiliation agreement with WICHE, on an interim basis, to benefit from WICHE's expertise in planning, while Nevada continues to plan for full autonomy with the University of Nevada as the grantee. Dr. Elliott, who represented the State Medical Society, spoke about inter- relationships at the state level which could be strengthened through an autonomous RMP--the Department d Health, State Medical Society and the School of Medical Sciences. An attempt was made to get an understanding of the "administrative stumbling block" which now prevents smooth and workable relationships with WICHE through the existing RMP structure. It was learned that no definite’ time has been set for Nevada's separation; the local group appears unanimous in its desire to withdraw from the four-state area. At the same time, the retirement of Dr. Popma later this year and the recent appointment of Dr. Joseph Deischer as State Director for Nevada, may influence the timing of autonomy for Nevada. Mountain States Site Visit Report -10- RM 00032 The Chairman of the site team expressed appreciation for the posture of Nevada in its flexibility of timing for autonomy and its constructive attitude about a separate Regional Medical Program. He referred to a planning application which would represent the organizational structure for such. autonomy and outlined the objectives, which ideally, such an application should incude. First, there should be a definitive design for the RMP in terms of. local capabilities and commitments. Also, a full description of a Nevada Regional Medical Program will be required by all reviewers and the National Advisory Council. Consideration must be directed toward all health interests - professional and voluntary organi- zations, hospital interests, desires of practitioners, etc. All will need © to be weighed, and hopefully, a "blueprint" for a new Regional Medical Program will emerge. This will require many months of study and . preparation. The site visitors discussed the "transition scheduling" in’ terms of a target date for separation, and the timing factors in line with preparation of new applications, review cycles, etc. The team suggested that perhaps a small group, which would be representative of WICHE, MS/RMP and Nevada, could meet to develop a plan of procedure, which in turn, could be presented for consideration of the Review Committee and the National > Advisory Council. The Chairman also pointed out that the split in South Dakota and Nebraska was not viewed by RMPS and the NAC as a precedent upon which Nevada (or-any other region) could build its case for secession, Each | case is a distinct phenomena and with many readily apparent differences. Nevada was complimented on its obvious destre for orderly procedure in the steps to establish autonomy. However, the need for an organizational - matrix to stimulate staff inter-relationships was emphasized in order to provide an environment for a series of dialogues, This should include, of course, identification of the requirements of WICHE as well as give due consideration to the needs of all four states. Doctor, Kevin Bunnell in stating the position of WICHE, expressed the opinion that all of the points raised: by Nevada:for becoming indédpendent, are capable of solution. He also pointed to the necessity of achieving mutually beneficial resolutions which will have to be negotiated with representatives of Reno, Boise and Boulder. REDUCTION IN PROGRAM FUNDS The site team was naturally concerned about the administrative format for setting priorities and decision-making within the present budgetary restrictions. Regional representatives pointed out that the Executive Committee, working with the MS/RMP RAG, will develop recom- mendations for cuts, In turn, the four~state Core staffs will develop their recommendations, and a combination of the two sets will be formed. These will again be reviewed by the Executive Committee, and if necessary, by each State Advisory Group. After full agreement, the list will be presented to the RAG which has authority for final decisions. s Mountain States Site Visit Report -l1l- RM 00032 The regional priority system will be utilized in developing plans for phasing out, termination, cut-backs, etc, of existing programs. An attempt will be made to maintain program viability in all four states, A number of ecSnomies can be effected in travel, meetings, elimination ‘of RMP funds for the Cancer Registry after December 1, 1971, consolida- tion of fragmented training programs below the eight current ones, exploration of a variety of ways to assure that the Mountain States Cancer Institute would not need to receive significant funding beyond two years from now, etc. The MS/RMP hopes to effect such reductions in line with recommendations of the site team, particularly as regards the design for a transition from coronary care-intensive care activities to other broader concepts for RMP, utilizing such facilities and personnel to a maximum extent. SUMMARY OF FINDINGS AND RECOMMENDATIONS 1. The region exhibited expert know how in developing an effective network For health planning in this large four-state area. The Regional Director has been successful in recruiting and retaining excellent Core staffs. Sub-regionalization through the establish~- ment of four state offices, plus the regional headquarters office in Boise, although expensive, is justified when one considers the significant impact of this means of distributing Regional Medical Program activities to many communities of varying size throughout the four states. The Core staff should be encouraged to continue to plan, develop and implement new patterns of health services. 2. A real achievement for RMP is the emergence of the School of Medical Sciences in Reno, undoubtedly due to RMP influences in that. area. The next few years will be critical in its development and the region was cautioned that RMP has never been viewed as the mechanism for support for medical schools or undergraduate training. 3, The MS/RMP needs to direct its attention to better coordination of Continuing Education Programs, One means of accomplishing the reduction of such fragmentation would be by the development of a multi-disciplinary (involving all health professionals) approach. This should focus on comprehensive patient care instead.of the professional disciplines involved, and develop into a team approach for continuity of patient care as well. This should afford a more economical and effective continuing education program, with improved utilization of manpower. 4. RAG membership needs broader representation. 5. The Mountain States Tumor Institute should attack its needs in grantsmanship without further delay, in line with previous details. It was agreed that RMP support for this activity should be limited Mountain States RMP Site Visit 10. ll. -12- RM 00032 to two more years. In developing the Scientific Advisory Committee: at St. Luke's, consideration should be given to the inclusion (per- haps by means of consultants or sub-committees) of other health dis- ciplines, such as nurses, educators, physical therapists, social workers, etc. This will assure that planning will be more relevant and comprehensive. MS/RMP and WICHE should attempt to coordinate the current influx of health professionals into all four states. ‘There was consensus on the part of the site visitors that the - mechanisms for decision-making are sound, well organized and managed. Further, the region was advised to apply the same ~ principles and tools that have demonstrated success in order to economize on diminishing RMP support. The Region has been most innovative in approaches to solving health problems. Lacking thus far are realistic thrusts in ‘the areas of hypertension and kidney disease. These needs should be addressed in due course. The separation of Nevada issue was thoroughly explored with all interests, There was agreement among the visitors that initiation of a series of dialogues should now begin. with all parties represented with a view to the establishment of meaningful and mutually benefi- cial RMP organizations. Developmental Component - Approval in amount requested - $71,000. The region is fiscally sound, mature in management, and has demonstrated responsibility in program development and decision- making to warrant the flexibility of judgement and ability to direct its own Regional Medical Programs affairs. Continuation of Core staff support and all operational activities, as follows: 7 MOUNTAIN STATES RMP - 13 - RM 00032 Recommendation Project No. and Title Requedt 04 Year 05 Year 06 Year Developmental Component 71,000 § 71,000 $§ 71,000 $§ 71,000 CORE 1,159,109 800,000 850,000 875,000 #2R-Coronary Care Training 148 ,582 100,000 -0- ~0- *e#3R-Tumor Institute 207,172 200,000 150,000 **50 ,000 #5-CE for Health Prof. ‘76,177 70,000 70,000 #***50 ,000 #6-Tumor Registry 166,271 100,000 -0- -0- #7-CE for Nursing (Nevada) 91,271i, 70,000 50,000 -0- #8-Inhalation Therapy CE 76,068 ~ 50,000 50,000 56,000 #9-Cardiac Care Training (Nevada) 70,737 . } 70,000 70,000 ##€k70 {000 @ #10-Consulting Teams (Nevada) 33,343 #11-CE for Nursing (Idaho) 89,255 50,000 50,000 *k*50 ,000 #12-Coronary Care Training (Idaho) 88 ,827 60,000 50,000 #*k*50 ,000 #13-CE for Nursing (Wyoming) 77,308 50,000 50,000 ***50,000 #15-CE for Nursing (Montana) 94.820 ‘50,000 50,000 ***50 ,000 TOTAL $2,449,940 $1,741,000 $1,511,000 $1,366,000 *200,000 $1,711,000 Region currently supported - $1,873,974 ! *For New Projects implementation - $200,000. *kTumor’ Institute to phase out in 05-06 years. *kkRecommend phasing out by 06 year to make these funds available for new programs. RMPS /GRB/5/5/71 NASSAU-SUFFOLK REGIONAL MEDICAL PROGRAM 1919 Middle County Road REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL APPLICATION (A Privileged Communication) Centereach, New York 11720 PROGRAM COORDINATOR: RM 00066 5/71 April 1971 Review Committee Glen E. Hastings, M.D. This application requests operational status and. funding for the Nasaau- Suffolk RMP. Prior to South Dakota's independence starting in planning, Nassau-Suffolk was the only one of 55 RMPs still in planning status. OL O20 03 04 Total Core $ 451,755.$ 490,408 $ 530,043 0 $1,472,206 ‘#1 Home Care 95,182 95,260 97,603 . $72,448 360,493 #2 Stroke 72,111 94,196 118,426 0 284,733 #3 Pap Smear 95,956 105,468 106,557 0 307,981 #4 Reg. Med. Library 46,860 46,750 48,994 ) 142,604 #5 Radiation Rx 27,830 19,085 19,085 0 66, 000 #6 Smoking 27,910 7,050 4) 0 34,960 #7 Computer Assisted Electrocarditology 302 , 632 92,576 58,788 0 453,996 & Spirometry #8 Training Community Health Asst's & 109, 382 67,225 46,860 0 223,467 Advocates , #9 Drug Info. Center 146,316 149,511 154,019 0 449, 846 #10 Clinical Nurse . Specialist 53,762 55,550. 0 0 109, 312 #11 Dial Access 37,525 38,416 39, 306 0 115,247 - TOTAL $1,467,221 $1,261,495 $1,219,681 $72,448 $4,020,845 Indirect costs allowance is not requested. Instead, 10% of direct NOTE: as fiscal. agent. (Core - $40,747 and 10 projects - $89,686). costs are budgeted for sub-contracting with Stony Brook Foundation Fiscal fees budgeted the first year total $130,433. Nassau-Suffolk RMP -2- RM 00066 5/71 SUMMARY OF PLANNING PHASE FUNDING: 01 (8 months) 02 . Total 1/69-6/70 7/70-6/71 } a, ; $263,011 $350,269 $613,280 | BACKGROUND: This Region encompasses Nassau and Suffolk Counties comprising 100 miles of Long Island east of Queens, The area was originally included in the Metropolitan New York Regional Medical Program, The efforts to begin a separate region began with the formation of a Advisory Medical Group in 1967. In June 1968, the Group incorporated as the Nassau-Suffolk Regional Medical Program, Inc. operating within $10,000 contributed by eight interested agencies. More than eighty organizations supported the new region in its planning. The Metropolitan New York Regional Medical Program agreed with the two counties that it was reasonable that Nassau- Suffolk Counties form a’separate region having geographic capability with other major relative organizations, e.g., the Long Island Hospital and eS Health Planning Council; the State Health Department for CHP; the Nassau- Suffolk Regional Planning Board, financed by HUD for planning in housing, economics and educational development; and the New York State Department of. Mental Hygiene. Distance and transportation posed difficulties in. developing vital relationships between the counties’ health professions and a the metropolitan N.Y, medical centers. The new Health Sciences Center being = ' +>... developed at the Stony Brook Campus of SUNY had brought: medical center i competence directly to the N-SRMP. The developing Stony Brook Health Sciences Center is to include Colleges of Medicine, Dentistry, Nursing and Allied Health; a School of Social Work, a Health Sciences Library; a University Hospital; and a VA Hospital. Other resources in the region include 41 hospitals, county health departments, several specialized research facilities, and the Brookhaven National Laboratory. The planning application was reviewed by the Review Committee and Council in the December 1968 cycle. Planning objectives: improvement in the delivery of medical services to all people in the community; extension of professional education; increased public education and the development of more extensive research, particularly in epidemiology and etiology. The Committee believed that the regional assets compensated for the lack of specificity in the application. In response to questions raised by the Committee, the Region named previously unspecified members of the Executive Committee and added 20 non-corporate members to the RAG, Additional information about staffing patterns was also provided. Although Council had the additional information, it shared the Committee's concern about the Region's heavy emphasis on computer and epidemiological personnel. Support was approved for two years of planning beginning January 1, 1969 (01 - $223,256 and 02 - $320,024). Because of difficulties in personnel recruitment there was little activity until the appointment of the current Program Coordinator on June 1, 1969. For this reason, the first grant period was extended from 12 to 18 months ‘Nassau-Suffolk RMP -3- : RM 00066 5/71 © with no additional funds. In lieu of indirect costs, the award was amended authorizing an increase of $29,755 the first period and $30,245 the second period for fiscal agent fees. The fiscal agent ia Stony Brook. Foundation, Inc. , The second year planning continuation application was reviewed by RMPS ‘staff. Needed refinement of objectives and activities as outlined by the Program Coordinator's letter of October 7, 1969 were noted. Region- alized cooperative arrarigements and program development had quickened with the appointment of a Program Coordinator and subsequent employment of staff. Staff agreed that satisfactory accomplishments coupled with projected activities reflected continuity and movement toward effective operational status in 1971. Of particular interest, was the link with CHP and the Long Island Health arid Hospital Planning Council. The Program | Coordinator heads both RMP and CHP and office space is shared. The Health | and Hospital Planning Council is also considering joining the sharing of quarters, DEMOGRAPHY AND. GEOGRAPHY: FP Long ‘Island Sound Atlantic Ocean New York - A) Population: Nessau County - 1,428,000 Suffolk County - 1,011,000 2,438, 000 Urban: Nassau - 99.7% Suffolk - 77.3% Racial: Nassau - 97% white Suffolk - 95% white B) Land Area: Nassau - 300 sq. miles Suffolk -.922 sq. miles 1,222 Nassau-Suffolk RMP -4- . RM 00066 5/71 C) Facilities: The State University of N.Y. at Stony Brook is in the process of developing a Health Sciences Center to include Colleges of Medicine, Dentistry, Nursing and Allied Health Professions; a School of Social Work; Health Sciences Library; a University Hospital (600 beds); and a VA hospital (750 beds). There are 41 hospitals in the region with 35,840 beds. D) Health Manpower: 3,121 physicians (Nassau - 2106 and Suffolk - 1,015) 124/100, 000 6,981 nurses (Nassau - 4,143 and Suffolk - 2,838) 280/100, 000 GOALS: The long range goals are: 1) To improve the distribution, accessibility, volume capacity, cost effectiveness, and quality of personal health services available to all residents of Nassau and Suffolk Counties; and 2) To develop mechanisme intrinsic to the health care system which will permit systematic ongoing identification and documentation of unmet health needs and the evolution of alternative solutions to meet those needs. Immediate goals, as detailed on page 13 of the application, deal with innovations in continuing education for allied health manpower, public education and cooperative health planning. Objectives for the first 12 months are described beginning on page 13. PRIORITIES: Priorities have been developed and because of their relevance to the projects discussed later in the summary are worth repeating and are appended. Protocal for ranking projects by priority is enumerated in section II of the appendices. Each project has the porential scoring of 10 to 100 against two criteria: 1) where it falls in the Priority List; and 2) its intrinsic merit. STRATEGY: A multiple-leveled program strategy has evolved from the planning process. It is based upon NSRMP's general conclusion that many, if not most, of the major problems of delivering health services to victims of heart disease, cancer, stroke, renal disease, and related diseases, are not unique to victims of these afflictions, but are problems afflicting the entire health care system, Therefore, NSRMP proposes that improving services for victims of the categorical disease can best be done by addressing major flaws in the health care system itself. Nassau-Suffolk RMP -5- RM 00066 5/71 "The basic program strategy of N-SRMP is to develop mechanisms within and outside of the health care system to establish and legitimatize consensus planning as a mechanism for building commitment to change parallel with the implementation of needed changes in the health care delivery system." ORGANIZATION: Organizational structure and project review charts are appended. The bylaws provide for two classes of RAG memberhsip, 25-100 corporate and 20-50 non-corporate. There are three minority ethnic members and twelve consumer representatives. The prescribed membership ratio is 3 corporate to 1 non-corporate. According to the rosters, the current RAG consists of 82 members (63 corporate and 19 non-corporate). The RAG meets every three months, It has responsibility for approving all contracts and | applications and receiving quarterly reports from officers of all expend- itures and actions undertaken by the corporation. Non-corporate members may not hold office as an officer or member of any Committee of the Corporation or the RAG, The Board of Directors consists of 30 members representing appropriate disciplines and/or organizations described in the bylaws. At each annual meeting of the members, ten directors whose ‘terms expire are elected for three years by the corporate members. The Board meets during at least ten months of the year and their duties include managing the business in the months intervening between RAG meetings. The Board shal! also submit at each quarterly meeting of the RAG a detailed report of the Corporation's progress during the previous quarter. The Executive Committee consists of the four officers of the Corporation and the Chairmen of the three standing committees of the Board. The ' Executive Committee shall conduct the affairs of the Corporation between meetings of the Board of Directors. The officers of the Corporation (President, Vice President, Secretary and Treasurer) are elected by the RAG at the annual meeting. Candidates must be directors. There are three standing committees of the Board of Directors. They are Administrative, Program and Evaluation, and Membership. Standing committees of the RAG: nominating and aims. Other committees (ad hoc): Health Information and Communication Systems; Cancer; Editorial and Public Relations; Education; Finance; Heart; Personnel Practices; Project Ranking; Stroke; Renal Disease: and Reaptratory. CHP and RMP staff functions have been integrated. There is a formal line organization for contacts outside of the organization; developing new staff activities and relating them to the RAG or ite subsidiary group; and employee accountability and evaluation. Alternate organizational forms which allow for maximum employee participation are used for problem-solving and technical task performance. Core tasks are divided into three categories: 1) organiz- ation maintenance (41.7% time); 2) planning tasks (38.9%); and 3) project- related tasks (19.4%). Nassau-Suffolk RMP -6- RM 00066 5/71 Formal geographic sub-regionalization is not planned, The rationale is that the region is small and there are rapid changes in population concentrations. RELATIONSHIPS TO OTHER HEALTH PLANNING PROGRAMS: The major relationship is with CHP. Eighteen members of the RAG serve on the N-SCHP Council and five are represented in executive groups of both organizations. Three CHP volunteer members serve on the RMP Aims Committee. There has been a merger of staffs, as well as Committees on Health Information and Research. Negotiations are currently under way for a total merger. There are cross reviews of projects by CHP and RMP. N-SRMP and N-SCHP continue to explore merging with the Long Island Health and Hospital Planning Council, including office sharing. Meanwhile N-SRMP and N-SCHP review a11 construction applications to LIHHPC. Likewise LIHHPC staff assist in the review of RMP and CHP proposals involving construction and renovations. RAG representatives also serve on the Suffolk Task Force on Hospitals and Health Related Activities. The Task Force, four years old, is to devise a long-term master plan for allocating public funds for health. The Region is participating by a contractual arrangement with Harvard University Center for Medical Care and Health Services Research in a multi-regional project designed to identify useful evaluation criteria and techniques. Relationships also exist with the New York State Health Planning. Commission, H.E.W. Region II, and the Nagsau-Suffolk Planning Commission. The application includes a core staff consultative activities list of approximately 150 Agencies indicating that cooperative arrangements exist with practically all resources. EVALUATION: Some steps relevant to both program and project evaluation have already been taken. Several steps will provide baseline data for measuring future progress: some steps are to increase the region's acceptance and use of evaluation as part of planning; and some steps have lead directly to project proposals and future planning efforts. ‘ The N-SRMP has studied the evaluation experiences of other regions, a& well as soliciting other regions’ comments on its own approach, Outside consultation is being sought as evidenced by the Region’ participation in the multi-regional program evaluation through the Harvard Center. Nassau-Suffolk Regional Medical Program -7]- RM 00066 5/71 PRESENT APPLICATION: Core support is for three years. One project is for four years, eight for three years and two for two years. A developmental component is not requested. Each of the projects received preliminary review and comment by staff and the appropriate categorical disease, or other ad hoc committee. ' These reviews were made in the light of: a) assessment of the technical merits of each proposal; b) the prospects of merger with similar pro- posals; c) the prospect of extending the proposal's organizational base so as to develop the widest possible number of "cooperative arrangements" between different organizational groups; d) suitability of the project for funding under the guidelines of PL 89-239; e) exploration of alternative funding sources; and f£) potential ofithe project for supporting future planning activities. Of the original 41 project outlines submitted for the development for RMP funding, 16 were withdrawn by the project authors. The remaining 25 were reviewed by the Program and Evaluation Committee, Aims Committee and RAG. RAG final recommendations include considerations by 22 of its sub-review bodies. Only 12 projects were approved, one of which was subsequently withdrawn by the applicant. Project numbers represent their priority rank order as approved by the RAG November 12, 1970. CORE: The request reflects an increase of about 25%. Requested Personnel ($302,587) includes nineteen First Year positions all of which are filled except two. Pro- $451,758 fessionals include the executive director, two assistant directors, two planning associates, one coordinator for planning and evaluation, one administrative associate, one health educator, one systems specialist, three planning assistants, and one (M.D.) coordinator for continuing education. The director and one planning assistant are paid 50% from RMP funds and 50% from CHP. Six secretaries are. budgeted - (4 full time and 2 part time - 130%). The amount of $40,747. (10%) is budgeted for the fiscal agent. Core activities in the planning years have included 9 feasibility studies. Data collected include available health facilities and services in Long Island, health training programs, and geographic distribution and socidlogical characteristics of health professionals in the region. Un- met needs have been inventoried and objectives and priorities set. Objectives for the first operational year: develop and secure funding for health projects which incorporate new regional cooperative arrangements and address problems of major regional importance; enhance visibility, utility and credibility of N-SRMP among both providers and consumers of health care; establish mechanisms for regional and subregional consensus planning and resource sharing both inside and outside of RMP; enhance the informational data base useful in health planning decisions; devise methods of evaluating N-SRMP's impact upon the health care system; Nassau-Suffolk ; Regional Medical Program ~8- RM 00066 5/71 address directly some of the region's gaps in health care delivery and ed- ucation through funding of projects in this application; enhance the level of expertise for developing innovative and effective continuing education; and further cooperative integration of N-SRMP with the activities of other planning and program development agencies. The work plan also includes a description of proposed activities. Second year: $490,408 Third year: $530,043 Project #1 Comprehensive Home Care~= The project aims Requested at improving ' First Year services to patients with heart disease, cancer, stroke $95,182 and related diseases by seeking solutions to problems inherent within the health care delivery sytem. The project is related to the Project #2, Stroke Referral and Evaluation, in that both provide mechanisms for coordinating the services available to the chronically ill and the handicapped. ‘The Home Care project seeks direct resolution to substantial organizational marketing problems in the delivery of home health services, while the Stroke Referral and Evaluation project serves principally as a patient protection device coordinating care of chronically disabled persons across all levels of care (hospital, ECF, home care, ambulatory care, nursing home). The Stroke Referral and Evaluation Program thus will provide a data base from which both formative and summative evaluation of the Home Care Program's effectiveness in improving patient care may be assessed. The proposed activities of Phase I of the Comprehensive Home Care Project are to identify and seek feasible resolutions to the existing market constraints and organizational constraints limiting the delivery of comprehensive home health services. PhasesII and III will establish financially self-sufficient administrative mechanisms through which home health services in Nassau and Suffolk Counties may be coordinated and integrated; through which administrative, cost accounting, and patient records keeping procedures may be standardized; and through which inefficiencies, duplication of effort, and disproportionately high administrative overhead costs may be reduced. Phase II involves pilot testing individual administrative mechanisms in selected areas and/or agencies and Phase III involves extension of successfully piloted mechanisms to all participating agencies. The project will provide an organizational planning mechanism and a systematically obtained data base from which the level of need for ancillary home health services may be documented and those services added in a preplanned, integrated fashion. The program represents the next step in the integrated planning and development of Home Health Services in the Nassau-Suffolk area which has grown from the Nassau-Suffolk Task Force on Home Health Services.- The project addresses the problem of delivering home health services in a more costs-effective manner, and of improving the availability, accessibility and volume capacity of home health services available to the residents of this region. These are priority I concerns of the Region. Nassau~Suffolk Regional Medical Program -9- RM 00066 5/71 The project includes an evaluation component. Also included are letters of endorsement from 23 agencies. If the project succeeds in establishing administrative means to permit greater cost effectiveness in delivering . home care, it is anticipated that those administrative structures will continue indefinitely as a legitimate overhead expense for participating agencies, with the cost of the expense defrayed through conventional third party payments. Second Year: $95,260 Third Year: $97,603 Fourth Year: $72,448 Project #2 Stroke Evaluation and Referral~ This project _ Requested is designed First Year to improve access to coordination of the community $72,111 resources available to stroke victims residing in Nassau-Suffolk Counties and their families. It will further document areas in which needed services are not available or accessible and the reasons behind lack of accessibility to existing resources. The project will provide: 1) a service function by coordinating available resources to the benefit of stroke victims; 2) an ongoing planning function through identification of existing "gaps" in services; 3) an evaluative function through sequential reassessment of the functional abilities of stroke victims; 4) an educational function through identi- fying areas in which informational deficiencies of health professionals may hinder the appropriate use of community resources in dealing with the problems of stroke victims and their families and through assisting in the development of "stroke census" in community hospitals; and 5) a research function through the identification of social, therapeutic and biological determinants of successful rehabilitation. The project will pursue these objectives by augmenting an existing centralized stroke registry by instituting a system for more rapid identification of stroke victims, by providing periodic assessment of the functional capabilities and health service needs of stroke victims and providing a referral mechanism to insure that contact 1s initiated between each stroke victim and the agency or practitioner with skills relevant to each victim's needs. The project staff will also provide a direct educational service by assisting community hospitals in the organization and operation of "stroke teams‘ Measures of the effects of therapeutic intervention, social factors, and biological determinants upon the rehabilitation potential of stroke victims will be measured in terms of death, disease, progression, disability, social disruption and professional and family satisfaction with both the services provided and the rate of rehabilitation. At the end of the third year of RMP funding, if successful, the program, will be continued through a combination of local and state funding sources. If the project proves to be unsuccessful, it will be discontinued, Nassau-Suffolk Regional Medical Program -10- RM 00066 5/71 Its high priority lies in that it addresses the problem of improving the coordination and integration of existing services to a particular category of patients with important therapeutic service needs (a Priority I problem). It is aimed at improving access to available services (also a Priority I problem). It aims at improving the coordination of home health services (a Priority II problem). The present project builds upon a strong base of acceptance among the laity, among the physicians, among voluntary agencies and among health facilities, previously established through the existing stroke registry. The project contains the potential for expansion into a regionwide patient referral and evaluation network for victims of all chronic diseases. The program is related to project #1, Comprehensive Home Care, in that many of its patients will at one time or another be referred to one or more home health agencies. The project is also related to the proposed educational resource désigned as a core staff activity, in that it will provide data regarding educational needs of health professionals. It will also provide information regarding needed additions to the Dial Access Lecture Program. oo Second Year: $94,196 Third Year: $118,426 Project #3 Development of Pap Smear and Breast Examination Requested Para-Professional Personnel- The purposesof this First Year project are twofold: a) to recruit, train, introduce and $95,956 demonstrate the usefulness of a new type of paraprofessional health worker in the Long Island community; b) to provide mechanisms for earlier treatment of uterine and breast cancer among high risk, low income populations through improvements in case findings, public education and accessibility to diagnostic services. For each of three years, seven residents from 4 low income, predominantly black community will be recruited and trained in the techniques of: 1) procuring specimens for Papanicolaou examination by the direct cervical scope technique; 2) obtaining Papanicolaou specimens by the vaginal irrigation technique and 3) instructing other residents in the techniques of self: breast examination. The newly trained health worker will elicit public participation in the program by: 1) direct door-to-door personal contact; and 2) public appearances at community meetings. Five of the newly trained health workers will remain in employment at the Martin Luther King Neighborhood Health Center in Wyandanch, the training and diagnostic center. Those workers trained during the second and third years will be employed at either Public Health Depastments and/or voluntary health facilities in the region. @ Nassau-Suffolk RMP -11- RM 00066 5/71 Followup care and definitive treatment of patients found to have examination . abnormalities will be provided through the Martin Luther King Neighborhood Health Center and Good Samaritan Hospital. Its high priority ranking is based upon the following considerations: 1) it is aimed at improving accessibility of a highly needed service to a low income, high risk target population lacking access to the service (Priority I); 2) it aims at improving the cost-effectiveness of health care delivery by delegating a technical skill normally performed by a physician to a non-professional worker (Priority 1); 3) it provides entree into the health careers for disadvantaged recruits (Priority I). It is also reported that the project's site is important as the expanding population of Suffolk County will probably promote rapid assimilation of newly trained health workers. The project blends with the Suffolk Health Department's plans to extend the number of its ambulatory care facilities to five low income target areas ‘over the next five years. The project relates to the health manpower development program presently being developed by RMP-CHP staff and Labor Department officials, local educators, and health industry employers. Although reducing mortality from uterine and breast cancer is the major aim of the project, this goal will not be measureable due totthe lack of © unreliable data and the short project tenure. The project will be evaluated in terms of achieving a projected number to be trained and screened. Two thousand women will be screened each year for uterine cancer and will have learned self: breast examination. Fifteen para-professional health workers will be trained and it is anticipated that 90% will remain employed in the health field after termination of the project. Second Year: $105,468 Third Year: $106,557 Project #4 Regional Medical Library Service and Training Requested This project addresses the need to improve the First Year avallability, quality and techniques for use of medical library $46,860 services in the region. It involves four major objectives and areas of activity: 1). the establishment of both in-service and collegiate training programs in the region for a new category of health manpower, to be called Medical Library Technician; 2) the establishment and upgrading of library resources and services available in (and to) all community hospitals. in the Nassau-Suffolk region; 3) the development or expansion of hospital committees charged with continuing responsibility for hospital library and educational resources . and services; © 4) the establishment of a functional regional educational library and information network among all health institutions for the purpose of securing optimal availability and use of regional resources. Nassau-Suffolk RMP a -12- ‘RM 00066 5/71 This project will involve all of the hospital medical libraries in Nassau and Suffolk Counties, as well as the libraries of the two county Medical © Academies, and the library of the Health Sciences Center, S.U.N.Y. at Stony Brook, (where project staff will be located). The project addresses the Priority I area of concern; the more efficient wse of organization and personnel resources through improving the level of resource sharing. The prdject includes an evaluation component. The Department of Library Sciences of the Health Sciences Center of SUNY at Stony Brook, the grantee,. will assume responsibility for continuing the activity after cessation of the grant. Second Year: $46,750 Third Year: $48,994 Project #5 Computerized Radiation Therapy Treatment Planning | Requested Service< This project proposes to develop First Year a technical service providing Computerized Radiation $27,830 Therapy Treatment Planning which can be utilized by hospitals of all sizes and by private medical offices concerned with radiation therapy planning in addition to the major institutions where it is now available. Nassau Hospital, Department of Radiation Therapy, will function as the central station for the project, receiving proposed treatment plans from participating hospitals or private offices by telephone or telecopier. The information will be reviewed by a physicist for the purpose of program development by a computer. Simple programs will be immediately run by the Nassau Hospital computer; complex programs will be sent by messenger to Grumman Data Systems. The completed program is to be returned to the sender within 24 hours if by telecopier, or three days if by mail. , Experience with the development of the technical phase of this program and the functional relationships which are developed among the partici- pating institutions will determine the future of the program. It may remain limited to technical service or it may become a stepping stone towards a clinical oncology program. The priority given to this project was based on it meeting the following needs: (1y Priority I - Increase efficiency, coordination, cooperation, resource sharing and better referral between existing health services, professionals and agencies; (2) Priority II - develop a shared accessible, exhaustive, and continuously current regionwide health information system composed of manpower data, availability of health service, financing data and patient- related information; and (3) Priority III - improve the level of technical sophistication of. available services. Nassau-Suffolk RMP -13- RM 00066 5/71 The project is related to the development of a regionwide comprehensive cancer program as is the Pap Smear and Self Breast Examination project. It aims toward the evolution of a regionwide health information system as do the Home Care, Stroke Referral and Evaluation, Regional Library, Computerized EKG and Spirometry, and Drug Information Projects. It is also designed so as to reveal professional educational deficits in the area of eadiation therapy and thereby is related to the core con- _ tinuation education development activity. Parameters to be evaluated include the extent of utilization of the project services and the projects direct result on patient care. It is anticipated that the project will become self-supporting by the: participating institutions' purchasing its services. Second Year: $19,085 Third Year: $19,085 Project #6 Smoker's Withdrawal Workshop - The purpose Requested of this demonstration program is to decrease First Year the prevalence of cigarette smoking in Nassau and Suffolk $27,910 Counties. It aims at preventing the occurrence of symptomatic heart disease, carcinoma of the lung, chronic obstructive pkimonary disease, arteriosclerosis obliterans, carcinoma of the urinary bladder and other pathological conditions associated with cagarette smoking. The project proposes the institution of a series of "Smoking Withdrawal Clinics". The clinics would incorporate the previous experience of a wide variety of similar efforts nationwide. In addition, a number of principles drawn from the literature on behavior modification would be utilized which have not been incorporated into previous anti-smoking programs. The format was pilot tested for logistical feasibility in June and September 1970. Observation and curriculum development personnel will participate in all sessions. Thetr function will be to observe, in detail, what happens during the course of each session, and to make correlations and evaluations in relation to specific techniques applied and the observable results. The observation and curriculum development personnel will meet with those conducting the course along with the participants to determine which techniques are most productive and which are not. Succeeding workshops will then be altered as new experience is gained through the results of the ongoing evaluation conferences. Participants will come from two basic sources: (1) self referrals; and (2) referrals from health professionals, institutions, and servicesaggnucies. Self referral is to be promoted by the Tuberculosis and Respiratory Disease Associations, the Cancer Societies, the Heart Associations, both County Health Departments, and the participant hospitals. Public relations activities will include placing of posters in public places, radio spot Nassau-Suffolk RMP - -14- RM 00066 5/71 announcements, newpaper releases and flyers distributed in participant hospitals. Physician referral is to be encouraged by circulating flyers to all -. physicians in both Nassau and Suffolk Counties 30 days prior to each clinic. Special notices will also be sent to Department of Inhalation Therapy and Chest Service in hospitals, physicians working in Chest Clinics of Health Departments, Directors of Medical Education and Nursing In-Service Directors in all hospitals. The reason for the project ranking is that it relates to disease prevention and improving the availability and accessibility of a service, both Priority I concerns of the N-SRMP. RMP funding is to cease after eighteen months. If the program proves effective, the individual hospitals with modest support from the TB and RD Association, will continue similar programs. Second Year (6 months) $7,050 Third Year: -0- Project #7 A Regional Approach to Computer Assisted Electro Requested cardiography and Spirometry Proposal ~ This First Year project proposes developing the capacity in six of the $302,632 region's hospitals to administer computerized EKG's and spirograms. Only hospitals with both in-patient and out-patient facilities will be selected. The project anticipates that 40,000 patients of all races, incomes and levels of treatment will be tested. The goal of the project's first year is to prove that this technique is reliable and feasible as a screening tool and as a routine hospital test. The hospital environment provides the built-in referral mechanism necessary for proper patient treatment and validation of the computer programs results. Simultaneously, the project will tellect, store and analyze the demographic data. The data gathered by using a standard form, ‘ean be shared by the participants, as well as used for further planning. Once the techniques have been proven, the long-range goals of the project are to add additional computerized diagnostic tests and to expand the collection of shared data outside the province of the specific tests. Consequently, this project forms the basis for a hospital-based multi- phasic screening center and a regional data bank. The proposal addresses six health priority items established by the N-SRMP. Three of these are: (1) improving the availability of services by providing techniques for the consumer which do not exist at present; (2) improving the accessibility of services both in terms of geography and affordable costs; and (3) insure continuity and coordination of services by continuing the Task Force Committee for future program operation. Evaluation areas include: physicians and Hospitals use of and satisfaction with the system; cost benefits; use of screening data for i planning; and further development to include additional tests. eres Nassau-Suffolk RMP -15- RM 00066 5/71 It is anticipated that after three years, the hospitals will assume financial responsibility for the EKGs, spirograms and data processing. Second Year: $92,576 Third Year: $58,788 Project #8 Curriculum Development for the Training of Community Requested Health Assistant and Community Health Advocates First Year This project addresses the problem of designing a structured $109,382 educational curriculum for community health aides and community health advocates, based upon a preliminary task analysis of the functions actually performed by such persons employed in Suffolk County. The training program introduces a two-stage "career ladder" in that those personnel demonstrating the highest level of proftéiency as community health aides will be selected for training as community health advocates. Further career advancement beyond the second stage is the subject of on- going planning between the Suffolk County Community College, Suffolk E.0.G., Suffolk Department of Public Health and the Health Sciences Center, S.U.N.Y.. at Stony Brook. , The aim of the program is to formalize the training of underemployed low- income community health workers, so as to provide a more stable and better defined pathway into the health professions for such workers. The purpose of defining the training program and the skill level of such employees is to demonstrate the relevance of their experience and training to the functions performed by health personnel working at higher levels. The Health and Family Planning unit of the Economic Opportunity Council of Suffolk and the Suffolk County Department of Health have budgeted for positions in this new category of health manpower. In addition, the 12 Headstart centers and the several Bay Care centers in Suffolk County are also planning to utilize this category of health manpower if the proposed training program is successful. The Community Health Assistant program graduate will also find job opportunities with upward mobility in the hospitals of Suffolk County. The project relates a Priority I problem identified by N-SRMP, to improve the effective utilization of the skills of health workers. Its major thrust, however, is to build an improved access pathway into the health services professions for unskilled and under-employed residents of the area. If successful, the curriculum design might serve as a model for similar training programs. Demonstration of specific skills by graduates of this program might enable existing educational programs and institutions _ to modify the length of formal instruction required for Licenses Practical Nurse certification or certification in other health occupational categories. A team consisting of representatives of Suffolk County Community College, Suffolk County Department of Health, Economic Opportunity Council of Nassau-Suffolk RMP ~16- RM 00066 5/71 Suffolk, R.M.P., representatives of the enrollees and the consumers, a representative of the Division of Allied Health Professions at the S.U.N.Y. at Stony Brook, and outside consultants as necessary, will have the responsibility of ongoing, periodic and concluding evaluation of the project. The main objective of the evaluation team the first year is to test the effectiveness of the core curriculum in relation to performance of the Community Health Assistants. Modification of the curriculum during» the training period will be made when the need is indicated by the evaluation team. Evaluation tools are described in the narrative. RMP support is requested for three years, after which the training programs are to be funded through M.D.T.A. and local resources. Second Year: $67,225 Third Year: $46,860 Requested Project #9 - Regional Drug Information - The objective First Year of this project is to establish a regiona] $146,316 drug information system which will allow participating hospitals to collect, correlate and learn from adverse drug reactions. On the basis of the collected data and its analysis, the project would . then attempt to perform an ongoing educational activity for participating hospitals, for hospitals generally in the region, for nursing homes, community pharmacists and physicians. A network of communications services will be developed to include electronic<: =~ communicating devices, sub-regional meetings, newsletters, monthly work - shops for participating hospitals and a publicity 1 program to include radio and/or television. Mercy Hospital, having developed a diversified drug program over four years, will serve as the focal point. It is anticipated that the initial seven participating hospitals will be expanded to a regional network. The project addresses priority III relative to continuity and coordination of service, in addition to development of communication linkages and cooperative arrangements, The project will also be relative to improving the quality of care. The project also addresses priority VI - research and information deficiencies. The project director and his staff are to evaluate the program semi- -annually and submit annual reports to participants, interested individuals and RMP evaluation criteria are described. It is anticipated that the participating hospitals will ‘assume financial support of the project after three years. Second Year Third Year $149,511 $154,019 et Nassau-Suffolk RMP -17- RM 00066 5/71 Requested Project #10 - Clinical Nurse Specialist in a Small General First Year Hospital. The purpose of this project is to $53,762 explore the impact of the role of a clinical nurse specialist in a small general, non-profit community hospital with an affiliated free ~ standing health center. The concept of the "Clinical Nurse Specialist" as a practitioner, role model, supervisor of patient care, counselor- resource person, teacher, coordinator, change agent and researcher, will be implemented to demonstrate that this practice will enhance the quality of nursing care. One unique contribution of the study could stem from the continuum of care for the socially and economically deprived patients who could be followed through the health center. The clinical nurse specialist would ‘function in both the hospital and health center as the needs of her specific patients arose. She would be a role model to the nurses in the hospital, health center, and community for coordination of services. This study could determine if the clinical nurse specialist's role should become an integral part of the hospital structure in the near future. ‘It would also determine if, through involvement of other nursing adminis~ “trators in the surrounding community hospitals through workshops, con- ferences, newsletters and publicity, interest in the clinical nurse specialist's role can be stimulated and positions opened up. The project addresses five of the six problem areas identified by the Program and Evaluation Committee of the Regional Advisory Group, namely: accessibility (Priority II); continuity and coordination (Priority IIl); quality of service (Priotity IV); efficiency in provision of service (Priority V); and research and information (Priority VI). Evaluation will be accomplished by the project investigators and a committee of consultants. Methods focus on change in hospital staff response to the clinical nurse specialist's role and patient care. Good Samaritan Hospital, the applicant organization, will provide future funding if the project proves effective. Second Year Third Year $55,550 $-0- Requested Project #11 - Nassau-Suffolk Dial Access Lecture - First Year The Dial Acess Lecture Project is designed $37,525 to tap into and share an existing Dial Access Lecture program already in operation in Central New York RMP region and Susquehanna Valley RMP region. The activity will serve the goal of increasing the continuing educational opportunities for the health professionals of the Nassau- Suffolk RMP region, thereby improving the quality of health care in the region. The project's major costs are for telephone services. The project will supply lecture services for both physicians and nursing personnel in the region by utilizing a WATS line. Nassau-Suffolk RMP ~18- . RM 00066 5/71 The project proposes to extend the scope of existing services by supplying “ee current and frequent updated library references upon request. The existing program will be modified slightly to improve its function as a source for identifying practitioner's perceived educational needs. The project aims at improving the quality of health care (Priority Lil) and attempts to do so by providing access to a previously established Dial Acceas Lecture Program. A second attraction of the dial lecture project is its apparent enthusiastic popularity among the region's practicing physicians. Data obtained through the Dial Access program about physician perceived educational needs might provide useful input into the Core Staff Educational Development service. Information gathered through the Stroke Program, Radiation Therapy Planning Program, Computerized EKG and Spirometry Program, Drug Information System Program, and the Regional Ifbrary Service Program would all be useful in defining possible subject material for additional tapes. Evaluation includes determination of the utilization of the system, users satisfaction and querying the Regions health leaders. | There is no provision for continued support of this project after three years. Second Year Third Year $38,416 ae $39, 306 Planning Phase Funded OL 1/1/69-6/30/70 $263,011 02 7/1/70-6/30/71 350,269 Total $613,280 NASSAU+SUPFOLK REGIONAL MEDICAL PROGRAM Operational Application 01 TAVERECIRTEE 02 7/1/72-6/30/73 03 7/1/73-6/30/74 04 7/1/74-6/30/75 Request $1,467,221 1,261,495 1,219 ,681 28 Total $4,020,845 -19- COMPONENTS | BY DISEASE CATEGORY [HEART 4 # Projects 1 : Total $$ 302 ,632 i 2% $8 21% | { f . CARCER # Projects 2 Total $s 123,786 7% $s 8% Approved /un funded L Disapproved STROKE # Projects : 1 : Total $$ 72,111 % $s 5% a wethae KIDNEY 4 Projects 0 Total $$ 0 “%2$S + 0 REDATED DISEASES a Projects 0 Total $8 0 % $s 0 MULTICATEGOR ICAL, # projects 7 Total $s 516,937 % $$ 35% GENERAL # Projects Core Total $$ 451,755 % $s 31% i Dt 8 Train & junity Health Assts - - $109 ,382 . " PROPOSED 01 OPERATIONAL COMPONENTS Core $451,755 #1 Home Care 4 $95,182 #2 Stroke_ o $72,111. . #3 Pap Smear $95,956. COMPONENTS BY TYPE OF ACTIVITY TRAINING AND EDUCATION # Projects 6 _ Total $$ 421,755. % $s 29%". Approved /un funded “ Disapproved _ DEMONSTRATION OF PATIENT CARE - # Projects 5. , Total $s §93,711 4% $s | Approved /unfunded #4 Regional Med, » Disapproved - #9 Drug Info. Ctr. ". $146,316 10 Clinical Nurse Specialist $53,762 ‘#11 Dial Aecess $37,525 Library $46,860. : . . RESEARCH & DEVELOPMENT, #5. Radiation Rx 7 . “9 : Projects $27,830 Total $$ 0: Z$S : _ Approved /unfunded . #6 Smoking Disapproved _ $27,910 - 7 Computer ‘ Ce eee cay - ADMINISTRATION & PLANNING $302,632 - . 4 projects Core Total $s °451,755 2% $8 “41% Approved/unfunded Disapproved a RMPS/GRB-3/1/71 -20- NASSAU-SUFFOLK REGIONAL MEDICAL PROGRAM PRIORITY LIST Priority I (Urgent) Activities aimed at increasing accessibility of health care services, especially in relation to specific population subgroups currently ‘lacking access (e.g., the poor, the near poor, the elderly, the disabled, migrant laborers). Activities aimed at increasing health manpower availability or improving efficiency of manpower utilization. Activities aimed at increasing efficiency, coordination, cooperation, resource sharing and better referral between existing health services, professionals and agencies. Priority If (Important ) Activities aimed at innovative improvements in professional continuing education. Activities aimed at developing a shared accessible, exhaustive, and continuously current region-wide health information system composed of manpower data, availability of health service, financing data and patient-related information. Activities aimed at instituting health measures presently unavailable in Nassau and Suffolk Counties. Priority III (Necessary) Activities aimed at improving specifically those health planning mechanisms which are presently weak. Activities aimed at development of new rehabilitative and home health services. Activities aimed at improving existing third-party financing mechanisms for direct services. Activities aimed at innovative improvements in lay health education. Priority IV (Useful) Activities aimed at improving the bed-to-patient ratio of general care and ECF beds, or promoting their more efficient utilization. Activities aimed at improving the level of technical sophistication af auattlahta aarutana -21- 3. Activities aimed at reinvolving all physicians lacking hospital affiliation back into the mainstream medical milieu. Priority V (Relevant ) All other activities falling within the framework of PL-89-239. -22— ORGANIZATIONAL STRUCTURE NASSAU -- SUFFOLK REGIONAL MEDICAL PROGRAM, INC, - Regional Advisory Group (Corporate & Non-corporate Membership) Nassau - Suffolk RMP Incorporated (Corporate Membership) ° Stony Brook Foundation (Fiscal Agent) : Aims and Nominati . . a . Program Board of Objectives eominating . * . a and Directors Staff Committee onmrnittes Evaluation Committee Heart ws . J . Administrative Commitice : Comunittce _ Cancer @ Finance Commitice Committee | Stroke , = Personnel Committee Committee _d Renal Disease = By Laws Committce Committee 4 Education . Mernbership Committee Committee Respiratory Editorial and | Disease LJ Fulilic Relations Committee Committee Health Inforn:ation — and Communications Commiitce * * RMP + CHP TABLE OF ORGANIZATION | RMP/CHP Executive Director Hastincs * Administrative Associate ges te e Surey + cretarial/Clerical eo. Coordinator for Planning: and Evaluation | . Assistant Director Europe + eee eae ‘Planning Assistants Assistant Director Owen ning Assistant ee hoell- NX Assistant Directer Kress | : Pianning Associate Rani lton Planning assistant Fishel + Librarian wenze + Health Educator Miller . Planning Assistant Alson * | Students +. -€Z- , Planning Associate Education Specialist (unfilled) * Page * Roth * Planning Assistant Marcus * ; ~~ £70 (A Privileged Communication) . ' SUMMARY OF REVIEW AND CONCLUSION OF APRIL 197] REVIEW COMMITTEE NASSAU~SUFFOLK REGIONAL MEDICAL PROGRAM RM 00066 5/71 e FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: Approval for operational: status. for three years with the following conditions: 1) that the Region obtain. the services of an outside consultant(s) to assess the current organiza- tional structure including CHP-RMP relationships; 2) that the concerns of the reviewers be communicated to the Region; 3) thet the second year continuation application be reviewed by Committee and Council and include a site visit; and 4) that the level of funding be increased if significant progress has been achieved during the first year. The Committee also recommends Council policy statement on use of RMPS funds for computerized EKG and epirometry (Project #7). The Committee recommends approval of the amount requested for core activities: 01 - $451,755; 02 - $490,408; 03 - $530,043, For projects, $1,915,466 is requested the first year, $771,087 the second year, $689,638 the third year and $72,448 the fourth. The reduced amount of $378,006 is recommended each year for:three years. The total requested and recommended is as follows: Direct Costs * Year Requested Recommended oO} $1,467,221 $ 829,755 02 1,261,495 868, 408 03 1,219,681 908,043 04 72,448 7 On $4,020, 845 $2 , 606, 206 These ranges for the 02 and 03 year may be modified by action taken under conditions 3 and 4 above. CRITIQUE: The findings of the site visit March 25-26, 1971 were presented by the Chairman of the team, Major concerns! 1) organizational structure is cumbersome and the corporate non- corporate delineation of RAG does not seem functional; 2) the roles of the Aims and Program Committees have overlapping responsibilities; 3) CHP end RMP merging relationships seem awkward and may inhibit relationships with health care providers; 4) core staff hidden objectives are not clear; 5) need for more clearly defined operating objectives and necessary data base; 6) although working reasonably well, the review process seems unwieldy: and 7) the Coordinator is NASSAU-SUFFOLK RMP -2- RM 00066 5/71 well qualified but because of his dual role as director for both CHP and RMP, he does need e full-time strong administrative assistant to provide continuous central direction to core staff. Some of the projects were apparently developed early in the Region's planning phase, Projects were modified by steff assistance, rather than initiated by core. Additional proposals are now being developed, and some of these may have a higher priority than those for which support is presently requested. As reported by the visitors, the Region's accomplishments to date include assembling a staff and a fiscal basis; conducting a number of studies as enumerated in the application; and the forming of cooperative arrangements, Some notable progress was evident in that the Region has been successful in: 1) getting the black physicians and dentists together to embark on medica] practice and problem areas in the ghettos: 2) assisting the dentists in establishing e continuing education program; 3) assisting schools in establishing community school health programs; 4) assisting industry and labor in examining health insurance programs; 5) assistance in the design of pre-pay group plan foundation; and 6) providing technical systems assistance to induce cooperative sharing of computer hardware and software. Some of Committee expressed disappointment in the proposed projects and their relationship to the stated priorities. The Committee questioned the wisdom of RMPS funding research type activities such as computerized electrocardiography and spirometry (Project #7). and believed a Council policy statement might be appropriate. There was general agreement by Committee with the site visit findings and recommendations, The Committee believed the Region needed the challenge of operational status and recommended approval of core as requested and projects at a reduced median level ($378,000) as recommended by the site visit team, The Committee also recommended discouraging the Region from funding project nos. 7, 9 and 10. t 1 wh # le : a DEF. .aTMENT OF HEALTH, 8 Cae ius ie Ww ea Lonicdenital PUBLIC HEALTH SERVICE © be HEALTH SERVICES AND. MENTAL HEALTH ADMINISTRATION Date: March 30, 1971 Reply to | | | Alin of: , Subject: Quick Report on the Nassau- -Suffolk Site Visit March 25-26, 1971 (Stony Brook, New York) To: Divector ic] Regional Medical Programs Service ny ’ fi Through: Acting Deputy Director hee Regional Medical Programs Service i. SITE VISIT TEAM: Consultants | - RMPS Staff * John E, Kralewski, Ph.D. (Gaairman ) "Alan S, Kaplan, M.D. RMPS Review Committee Continuing Education Branch Edward D, Coppola, M.D. Spencer Colburn Consultant (Practicing Surgeon) > Paul E. Teschan, M.D. Director Tennessee Mid-South RMP * Chairman IL, STRUCTURE: The entire visit took place at the Region's Regional Developmental Branch Robert Shaw HEW Region I RMPS Rep. Lawrence Witte Program Planning & Evaluation Roger Miller Grants Management Branch Luther Says Grants Review Branch s headquarters with approximately 60 atea representatives. However, the meeting was structured along the lines previously suggested by the site visit team and the mission was accomplished through three major sessions an attended by appropriate persons. First Session (3 hours) 1. Organization and Decision~ Making Structure © - Legal Structure a - Governing Eodies d seven sub-group discussions Participants - Site Visit Team (9) - Officers (4) - Attorney -2 @ - Regional Advisory Group . ~ RAG Corporate members (4) : (3 consumers & 1 provider) - Chief Operating Officers - RAG non=corporate members. (4) (3 providers & 1 consumer) - Goals, operating objectives _» Chairmen (2) and Priorities ‘Aims & Program Committees + Activities Underway - Coordinator & Key Staff (3) + CHP & RMP relationships ~ Management Information System - Accomplishments Second Session (4 hours) 2. Operational Programs - Site Visit Team = Development = Officers (4) . “a - Review procedure - Chairmen (2) | @ ; Aims & Program Committees : - Role of RAG - Key core staff ~ Staff assignments 7 Project authors (10) - Priority assignment a ~ Medical Societies representatives (4) - Evaluation '- Hospital respresentatives (4) - Plans for phasing out _ - Dental Society (2) RMPS support - Regionalization ~ Health Department (2). - Cooperative Arrangements - University (2) - CHP representatives 3, Community Involvement Discussion Groups (4) 1, Project Authors -3- 2.. Health Institution Representative : 3. Planning Agency Representation 4. Community Representation “Third Session (3 hours) 4,. Staff Organization - Site Team and Activities ; -~ Line and staff organization ; ~ All professional core staff (9) - Task allocation ~ Personnel & turnover ~ Internal operation activities & accomplishments - Management controls including data base, monitoring and evaluation - Budget review ‘Discussion Groups 1, Budget review 2, Staff organization & management 3, Continuing Education 4,. Accomplishments Feed Back Session Observations & Recommendations - Site Team of Team (no mention of recommended funds) - Chairman of RAG - Key Core (9) T1i, SUMMARY OF FINDINGS: The multi-faceted organization was inherited. The RAG membership remains relatively unchanged since 1969 and a rather low level of attendance . of meetings was noted, The corporate and non-corporate membership appears to have created a cumbersome situation, ‘The question. arose as to the functional differences between the RAG (corporate and non-corporate t whe members), the Board of Directors (corporate members) and the Executive Committee. - fhe roles and interchanging relationships of the Aims and Program Committees are not clear and there is some question about their sense ef direction, The project review process was considered cumbersome but is -working moderately well. Of major concern to the visitors, was the merging functions of CHP and RMP, i.e,, integration of the two staffs, one staff director for both agencies and the merging of the two Aims "Committees A more. formal merger, is under consideration which is to include the Long Island Health and Hospital Planning Council. The visitors believe that this meld has contributed to the Region's waning influence with the medical community. Two separate and distinct agencies with interfacing relationships might be more effective. The Region's priorities are reasonable and relevant but there is a need for more clearly defined operational objectives and necessary data base. Core staff aversion to acquisition and use of data was apparent, Operational planning seems to be more by the "human" approach rather than the "quantitative" approach, "Hidden objectives” exist but are vapue, Internal affairs are on.a sound footing, particularly since the "Management Assessment Visit" conducted in July 1970 by RMPS, The Region is doing a good job in personnel management. Fiscal services, including purchasing and. prompt reporting, are adequate and the costs are very reasonable (10%). There was sone concern, however, about the many responsibilities of the Goordinator and the need for providing central direction to the staff. A full-time strong administrative assistant (deputy) is needed. Some of the projects were apparently developed early in the Region's planning phase. Projects were modified -by staff assistance, rather than’ initiated by core, Additional proposals are now being developed, and some of these may have a higher priority than those for which support is presently’ requested, The Region's accomplishments to date, include assembling a staff and a- fiscal basis; conducting a number of studies as enumerated in the application; and the forming of .cooperative arrangements, Some notable progress was evident in that the Region has been successful in: 1) getting the black physicians and dentists together to embark on medical practice and. problem areas in the ghettos; 2)..assisting the dentists in establishing a continuing education program; 3) assisting schools in establishing community school health programs; 4) assisting industry and labor in examining health insurance programs; 5) assistance in the design of pre-pay group plan foundation; and 6) providing technical systems assistance to induce cooperative sharing of computer hardware and software. a a. ~5~ © IV, RECOMMENDATIONS: “Approval for operational status for three years with the following conditions: 1) that the Region obtain the services of an outside consultant(s)} to assess the current organizational structure including CHP-RMP relationships; 2) that the concerns of the site visitors be communicated to the Region; 3) that the second year continuation appli- cation be reviewed by Committee and Council in addition to staff and 4) that the level of funding be increased if significant progress has been achieved during the previous year, The site visitors recommended approval of the amount requested for core activities ‘as follows: OL 02 03 $451,755 $490 ,408 $530,043 The first-year request for eleven operational projects is $1,015,466. Support is recommended at a reduced level in three ranges-as follows: Maximum $423 ,000 Medium 378,000 @ Minimum 326,000 : The total amount recommended for the O01 year at the maximum, medium and minimum amounts are: MAXIMUM MEDIUM MINIMUM Core $451,755 $451,755 $451,755 Projects 423,000 378 ,000 326,000 Total $874,755 $829,755 $777,755 These ranges for the 02 & 03 year may be modified by action taken under . 4 f i) . PuULbar pi QUA Luther J, Says, Jr. . Public Health Advisor ! Grants Review Branch ' RA AN FROL a ° L.J. Says SITE VISIT REPORT NASSAU-SUFFOLK REGIONAL MEDICAL PROGRAM March 25-26, 1971 SITE TEAM MFMBERS John E. Kralewski, Ph.D., Chairman, Review Committee Member, Chairman Health Administration, University of Colorado, School of Medicine, Denver, Colorado Consultants Edward D. Coppola, M.D., (Practicing Surgeon) Associate Professor in Surgery, Hahnemann Medical College, Philadelphia, Pennsylvania Paul E. Teschan, M.D., Coordinator Tennessee Mid-South Regional Medical Program, Nashville, Tenn. MPS Staff Alan S. Kaplan, M.D., Continuing Education Branch Spencer Colburn, Regional Development Branch Lawrence Witte, Office of Planning and Evaluation © Robert Shaw, HEW, Region II, New York City Roger Miller, Grants Management Branch Luther J. Says, Grants Review Branch REGIONAL REPRESENTATIVES Officers of NSRMP Edmund D. Pellegrino, M.D., President Reverend Richard P. Hendel, Vice-President Frank Gibson, Secretary Henry Bang, Treasurer Members of the Regional Advisory Group Costas Lambrew, M.D., Chairman - Aims Committee Edwin Clare, Attorney for RMP Leonard Andors, D.D.S. Ms. Priscilla Roe Leon Rushmore Lawrence Scherr, M.D. William Warner Nassau-Suffolk RMP -~ 2 - Project Authors Martha Browning, Comprehensive Home Care Lindon Davis, M.D., Stroke Referral’ & Evaluation Wm. Messinger, M.D., Regional Approach to Computerized EKG Paul Diamond, N.D., Regional Approach to Computerized EKG Walter O'Connor, M.D., Development of PAP Smear & Self Breast Exam Ms. Stacey Saley, ‘Regional Medical Library Ms. Elsie Wilensky, Regional Medical Library Perry Mandel, M.D., Computerized Radiation Therapy Harold Astorita, Computerized Radiation Therapy Sister Marie Buckley, Smoker's Withdrawal Ms. David Arella, Smoker's Withdrawal Daniel DePonte, Curriculum Development Sisiter Jane Marie Durgin, Regional Drug Information Clenna McLean, R.N., Clinical Nurse Specialist Emil Frey, Ph.D., Dial Access Lecture Health Institution Representatives John Dowling, M.D,, Nassau County Health Dept. Micheal Buscemi, M.D., Suffolk County Health Dept. Leo Fishel, M.D., Nassau County Medical Society Maurice Tulin, M.D., Nassau County Medical Society Milton Rosenberg, M.D., Suffolk County Medical Society Walter O'Connor, M.D., Suffolk County Medical Society Jack Dillman, Executive Director, Nassau~Suffolk Hospital Council Martin Nester, Administrator, Long Beach Memorial Hospital Francis Fosmire, Administrator, Brookhaven Memorial Hospital Richard Schoen, D.D.S., 10th Distric Dental Society Robert Brunner, State University - Health Sciences Center Planning Agency Representatives Henry Bang, Exec. Vice-President, Long Island Health & Hospital Planning Council Reverend Richard Hendel, Long Island Health & Hospital Planning Council William Warner, Chairman, Comprehensive Health Planning Council Ms. Louise Pan, R.N., Comprehensive Health Planning Council Ms. Joyce Turner, Comprehensive Health Planning Council Sanford Lenz, Comprehensive Health Planning Council Community Agency Representatives Arthur Risbrook, M.D., Clinical Society Sister Marcella Ann Hannon, Home Care Task Force Joyce Turner, Brentwood Schools* Mark Kenyon, Medical Foundation Eugene McNamara, Business/Industry Sanford Kravitz, Health Manpower John F. O'Donnell, BioMetric Systems Wm. Larregui, Suffolk County Task Force James Culhane, Suffolk County Task Force Louise Pan, R.N., Task Force on Nursing Education * *Ms, Pan and Ms, Turner represented their interests at both groups. Nassau-Suffolk RMP -3- Core Staff Glen E. Hastings, M.D., Executive Director, RNP & CHP John Kress, Assistant Director for Technical Support Steven Roth, Systems Specialist Sharon Hamilton, R.N., Planning Associate, Project Grants/Management & Development James R. Europe, Assistant Director, CHP Harrison Owen, Assistant Director for Organizational Liaison and Special Projects Robert Beckman, Coordinator for Evaluation and Planning Annette Gilpin, Administrative Associate Willie Paye, Planning Associate Nassau~Suffolk RMP -~ & « i PURPOSE: In light of the present initial triennial application for operational status, the site visit was conducted to study and assess the Region's program structure, achievements and capability. SLTE VISIT STRUCTURE: Prior to the visit, RMPS documents "BMPS Review Process Requirements and Standards" and "Prosram Review Criteria were provided to the Region and Oo the site visitors. The latter was used as a check list in structuring a the agenda and in the conduct of the visit. The entire meeting took place at the Region's headquarters with approximately 60 area representatives, However, the meeting was structured along the lines previously suggested by the site visit tean, and the mission was accomolished throuch three major sessions and eight smaller sub-grou a ao discussions, each attended by appropriate persons. The first session:(3 hours) with their otficers, some RAG members, the attorney and Key staff, focused on organization structure; goals objectives, and priorities, achievements, management information, and CHP-RMP relationships. The second session (4 hours) also included project authors, providers, consumers and other health interests groups, and “centered on operational programs (development, review, evaluation and phase out plans), and regionalization and cooperative arrangements, The discussions were further amplitied through four small groups;.1) project authors, 2) health institutions (Health Departments, Medical Secieties, Dental Society, Hospitals and University), 3) planning agencies, and 4) local organizations, Nassau-Suffolk RMP -5- The third session (3 hours) on the second day was with the principal staff and dealt with staff organization, task allocation, personnel, internal operations, management controls and budgets, Small discussion groups included 1) budget review, 2) staff organization and management, 3) continuing education, and 4) accomplishments, The meeting concluded with 2 one hour feed back of observations and recommendations (no mention of funds} to the Chairman of RAG and principal staff. SUMMARY OF FINDINGS: Until South Dakota's recent separation from Nebraska Nassau-Suffolk was the last of the 55 Regions still in planning. After two and one half years in planning, the NSRMP is now requesting operational status and initial support for core activities and eleven projects. Core funds are requested for three years, one’project for four years, eight. for three years and two for two years. I. Historical Develonment The Region encompasses Nassau and Suffolk Counties comprising 100 miles of Long Island east of Queens, The area was originally included in the Metropolitan New York Regional Medical Program, The efforts to begin a separate region began with the formation of a Advisory Medical Group in 1967. In June 1968, the Group incorporated as the Nassau-Suffolk Regional Medical Program, Inc, operating within $10,000 contributed by eight interested agencies. More than eighty organizations supported the new region in its planning, The Metropolitan New York Regional Medical Program agreed with the two counties thet it was reasonable that Nassau- Nassau-Suffolk RMP ~ & - Suffolk Counties form a separate region having geographic capability with other major relative organizations, ¢.@., the Long Island Hospital and Health Planning Council; the State Health Department for CHP; the Nassau- Suffolk Regional Plenning Board, financed by HUD for planning in housing, economics and educational development; and the New York State Department of Mental Hygiene. Distance and transportation posed difficulties in developing vital relationships between the counties’ health professions and the metropolitan N.Y. medical centers, The new Health Sciences Center being developed at the Stony Brook Campus of SURY is bringing medical center x competence directly to the N-SRMP. The developing Stony Brook Health Sciences Center is to include Colleges of Medicine, Dentistry, Nursing and Allied Health; a School of Social Work, a Health Sciences Library; a University Hospital; and a VA Hospital. Other resources in the region include 41 hospitals, county health departments, several specialized research facilities, and the Brookhaven National Laboratory. Support was approved for two years of planning beginning January 1, 1969 (01-$223,256 and 02-$320,024). There was little activity until the appointment of the Program Coordinator June 1, 1969 and subsequent staffing. For this reason the planning period was extended for six nonEhe until June 30, 1971 with no additional funds. In lieu of indirect costs, awards for direct costs including fiscal agent fees, $29,755 for the first grant period and $30,245 the second period. The fiscal agent is Stony Brook Foundation, Nassau-Suffolk RMP ~ 7- Of particular interest has been the Regions link-up with CHP "b'' and the Long Island Health and Hospital Planning Council. The Program Coordinator heads both RMP and CHP, and offices are shared by both groups, A more formal merger of the two agencies is under consideration. The Health and Hospital Planning Council is also considering joining the sharing of quarters. Il. Goals, Objectives & Priorities Operational planning seems to be more by the "human" rather than the “quantitative” approach, “The goals, objectives, and priorities have evolved from a “laundry list" of perceived problems. While the priorities set by the organization seem to be consistent with the needs of the country ‘in general there has been little effort devoted towards the collection of data to determine specific needs and priorities for the Nassau-Suffolk region. As a result the general priority list has net been developed into operational objectives other than for the staff to go forth and do good under the general direction of "hidden objectives”. The staff believes they can not promulgate these hidden objectives in writing because they would create too much anxiety among the health care producers, The "hidden objectives" were not clearly understood to the visitors, nor are they understood by all the core staff. There is need for more clearly defined operating objectives and necessary data base. LIL. Organization Structure eee ELT OT The Regional Advisory Group is made of 82 members with heavy representation from the medical community, The attendance of meetings has been about 40%, but it appears that those attending represent diverse interest groups including consusier and producer grouvs in approximately equal numbers. The Regional Advisory Group is composed of corporate and non-corporate members in approximately a three to one ration with the carporate members ey legally responsible for the agency and the entire group acting to advise the program in terms of goals and objectives, The delineation of these responsibilities is not clear to RAG members and most do not know whether they are corporate or non«corporate members, The RAG initially was the incorporating body but was expanded and split into a corporate non=corporate configuration when the propriety of the single board concept was guestioned by RMPS, Non-corporate members have all rights except that n observer on a committee if bas) of holding office, however, they may be appointed by the president, Eoth corporate and non-corporate members are elected to three-year terms without pay. Their function is to approve all contracts and applications for grants at the quarterly moetings. Two standing committees assist the RAG: 1) the Nominating Committee, and 2) the Aims Committee, The Nominating Committee, seven members elected by the BAG, nominates replacements to the RAG and its own committee, Nominations may also be made in writing by any five corporate members. The Aims Committee, composed of 10-30 voluntary members of the Advisory Group, considers available data concerning health needs, and assists the RAG in its development of short-range and long-range program goals, and makes recommendations to the Group. The officers are President, Vice-President, Secretary and Treasurer and are elected by the RAG. The same officers head the Corporation, the RAG, Board of Directors and Executive Committee, Nassaue-Suffolk RMP ~ 9 - The Board of Directors consists of 30 members representing designated health providers, health interest groups and consumers, The Board meets monthly and carries cut the corporation's business during the interim between quarterly meetings of the RAG to which it reports. The Board enploys the Executive Director as its chief administrator to carry out its policies and programs on a day to day basis, The Executive Director has responsibility to hire, fire, train, direct and supervise staff members, who are authorized by the Beard. In addition, the Executive Committee, composed of the four Board officers and chairmen of the three standing committees of the Board (chairmen are elected from the Board by the Board), conducts the affairs of the corporation in the interim between monthly Board meetings, at which time their actions are ratified by the Board, On the advisory branch are the three standing committees: 1) the Administrative Committee, which is in charge of the budget and financial policies, and forms job descriptions; 2) the Program and Evaluation Committee, which coordinates and reviews the program activities, and reviews all projects for possible funding; and 3) the Membership Committee, which recruits members and determines classification of members for recommendation to the Board. Membership on these committees and subcommittees are not restricted to members ot the Regional Advisory Group, and are chosen by the chairmen with approval from the Board. IV. Internal Affairs The Executive Director of N-S RMP is also the director ot the CHP areawide \ "hb" agency, CHP and RMP activities are therefore closely interrelated with both sets of activities carried out by a l6-man staff (ten paid by Nassau-Suffolk RMP - 10 - RMP and six funded by CHP. The roles of the various staff members are not well defined and there eppears to be some ambiguity as to who does what. This arrengement is further complicated by the fact thet fully half of this staff report directly to the Executive Director whose dual CHP=-RMP role leaves him ingufficient time for internal administration. The visitors believe a full time strong Administrative Assistant (deputy) is needed, Other than the need for providing better central direction to staff, internal affairs are on a sound footing, particularly gince the "Management Assessment Visit" by RMPS in July, 1970. Fiscal services, including purchasing and prompt reporting, are adequate and the costs are very reasonable (10%). ’ V. Program Accomplishments: Some of the projects were apparently developed early in the Region's planning phase. Projects were modified by staff assistance, rather than initiated by core. Additional proposals are now being developed and some of these may have a higher priority than those for which support is presently requested. Some of the newer projects considered, definitely seemed consonant with Regional Medical Program goals and offer the possibility of changing health care delivery in a significant way. However, these projects and ideas came along after the present operational application was submitted to RMPS and many of them have been incorporated into the new Comprehensive Health Planning application, When the Core Staff was asked how they could prevent themselves from being boxed in once the present projects in the RMP application had been started, the answer was that they will continue its local action Nagsau-Suffolk RMP ~ lhe and organizing activities in a consultative fashion, Optimistic signs .that this might be an effective way to go are that at least four or five medical community eroups have come to them asking for advice of various kinds. In order to handle what appears to be an increasing amount of advisory and consultative activity, Core Staff would subcontract for additional needs as they arise instead oi expanding its own number of personnel, The main way in which the Regi onal Advisory Group would appear to play a role here is through’ the Program Committee and the Aims Committee, The Core Staff feels that the potential for leadership in these committees : is fairly good. The major accomplishments of the program to date have been: .1) setting up a Core Staff which seems to be sensitive to community group dynamics; 2) working closely with the activist members of the program and Aims Committee of the Regional Advisory Group; 3) community organizing; and 4) responding quickly: and enthusiastically to requests from the professional medical community for guidance and assistance in approaching problems of health care delivery. Examples of such accomplishments are: - 1) Organization of the Nassau-Suffoik Clinical Society. This is an association of more then 80 black doctors and dentists which is addressing | itself to health care needs of the minority population. Sixteen Health Committees of this group have-been formed, which have both consumer and provider representation, They are interested in working on sickle cell disease and other problems peculiar’ to blacks. No project applications have yet come from this group but it is anticipated that they will. Nassau-Suffolk RMP -~ 12 = 2} School Health Oreanizations., The Core Staff is working with school districts since they are defined by neighborhoods and provide a means to get at a defined population, They are interested in the relationship of poor health to under-achievement in school and have gotten the health ct department and the school district officials to sit down together and & look at these problems. Health aides, nurses, and doctors are eradually being involved. 3) Labor and Industry Organizations. The premise here is that the way in which health care delivery can be influenced requires participation of influential community groups. ‘The Core Staff has talked with representatives of labor and industry and pointed out that they were spending $347, per year on employee health and the employees were spending again at least that much. It was pointed out that pre-paid care could probably do. the job cheaper and better, Various public utilities and private corporations are involved in these discussions, An informal group has been organized which has been meeting for a year and in the past year the membership of the group has doubled. These companies are currently spending $40 million per year on health. Insurance companies have been approached _ and representatives from them have joined the group. RMP Core Staff is vagssisting this group in planning. The response from the medical community has been either "non-pluged" or very interested, The Nassau Medical Society has made inquiries about being a potential bidder for such a health plan, 4) There are five other potential groups starting to look in this direction 4 and they have come to RMP Core Staff for advice and assistance, Nassau-Suffolk RMP ~ 13 + 5) & program for providing health care to the poor had been planned with the Riverhead Hospital, The Department of Health had committed $300,000 to this project and RMP was prepared to commit $100,000. The hospital had agreed to form a Department of Comaunity Medicine and hed approval of the hospital administrator and tne board of trustees, However, the program was defeated by one vote in a medical staff meeting, preventing its initiation, 6) & similar type of program is being developed at the Brookhaven Hospital although some details of ‘the arrangements are not quite the same as the Riverhead Hospital project. 7) Core staff are working with the evaluation component of the Southwest Suffolk Health Program which is a joint OEO-HIP program from 2500 welfare recipients, 8) Assistance is being given to the Suffolk County Health Department in preparing seminars for county legislators, ’ 9) Staff is also assisting the dentists in establishing a continuing education program. 10) Technical systems assistance is provided to induce cooperative sharing computer hardware and software, VI, EVALUATION: The Region has developed a critical pathways form for project monitoring. The concept was developed by the construction industry several years ago (also called PERT) and allows for month] Me mene Sy Fadi TEP Nessau-Suffol: baru ~ surveillance. Projected monthly accomplishuconte and expenditures may at 7 L be compared to ectuality. P y Most of the projects have an evaluation component but the Region's overall program evaluetion is vague, particularly in absence of data base. The USRMP hes studied the evaluation experiences of other regions, as well as soliciting other rexions comments on its own approach, Outside consultation is being sought as evidenced by the Regions participation in the multi-regional program evaluation through the Harvard Center. ~ Phase I of the Harvard study includes an interview study of 17 staff (10 paid by RMP and 7 paid by CHP), 27 RAG members (10 non-corporate and 1? corporate), and 25 non-RAG members. The latter 52 represented some of the most"influential people" including those in health care, Preliminary results indicate the Region's first order of priorities are congruent with major health problems identified by the respondents. The second order of priorities should be re-evaluated, The projects for which funds are requested address a large number of the Region's major heaith problems. All respondents agreed that the major purposes of NSRMP should be to plan and improve health care in general. The greatest current visibility of NSRMP seems to have been generated by ectivities unrelated to RMP projects per se, This phenomenon is to be re-examined after the Region is funded and operational. All respondents predict a merger between RMP and CHP at local and national levels and are otherwise uncertain of the future of RMP. Ma lfadic Tarp 46 NassaueSuffolk Dw he » lo « ONCLUSTONS: The organization lacks the rigor of a well-run firm, aan AAA 7 we CONCLL ta be loosely However, the presran is young and pre structured during the formative years to accommocare tne many interest eroups that provided the impetus for the development of the Regional oo 1 ret : Vr folk area, This was especially % true since they did not have a medicel school to provic le the leadership cy and programa, he siteevisit tean believed thet the cuality of the top leadership in the corporation was of a nature that would insure long-range success of the program. Therefore, while the team shared many reservations about the present organizational, structure and state of the corporation and program development, the visitors believe that the Region has a great deal of potential and will benefit from and consequently do justice to the challenge of an operational progran, Major Concerns: 1) The corporate structure is cumbersome and the corporate non-corporate delineation among the Regional Advisory Group membership is artificial and disfunctional, therefore, this area should be re-examined and possibly restructured, *2) The roie of the Aims and Objectives Committee versus that of the Program Committee is not well defined and as a result it appears that these two groups have overlapping responsibilities for the development ot long-range plans, A more workable arrangement should be developed for the determination of long- and short-range goals and the structuring of ‘ programs to meet those goals. . c Rassau-Suffolk RMP - Lé 3) The internal organization of the Reeion lacks structure and direction, oD As a result it appears that the orgenization is operating on a reactive rather than free-floating ith mo ciesr cut direction. we o mh Lea ee * ea) “A Be ct 4) The management informatioi ithin the operating level of the a 7 Me a ev Q 3 ad organization appears to be relatively minimal. Most of the employees report their progress to the director on an informal basis with few operating and little measurement #s te whether they are ectually achieving results. The methods by which the director reports to the board seems to be more structured although much of it is based on informal communications 5) The salary structure and d allocation of resources in the oxeeni zation appears to have been accomplished on a rather haphazard basis, Some salaries seem high for the kinds of talent being iced, It also appears that the ® various talents have not been brought together to form a composite group who would accommodate and build on each other's expertise, Some other Core budget items seem equally imprudent, i.e., remodeling costs (plan to relocate in thé near future) and consulting services for writing grant applications. The internal administration of the program should be thoroughly reviewed and strengthened. Consideration should be given to employ an administrator to provide continuous day to day direction, This is especially important since the coordinator heads both CHP and RMP activities. “6) The project review procedure is extremely cumbersome with the RAG being brought into the picture much too late in the process. Review procedures need to be streamlined. It was noted that the review procedure appears to have incorporated proper scientific and managerial reviews to insure integrity of each project although it is difficult to see how the projects c + Nassau-Suffolk RiP ~ 17 = fit into a total program, 7) Too little effort has been devoted toward generating projects that more realistically meet the goals of the organization. As a result the program is made up of projects developed on a more or less randam basis with little program consistency. 6) There is concern about the close relationship between the RMP and CHP and the evident confusion this has caused in the minds of the health care practitioners, Some of the site-visit team members were concerned that the Region has lost at least some of the support of the medical community. They believed that in part this is due to the close i celationship with CHP. 9) There has been little effort towards acquisition and use of data to determine specific needs and priorities. As a result the general priority list has not been developed into operetional objectives. Also there are too many hidden objectives. 10) Levels of attendance is relatively low at the Aims and Program Committee meetings when the priorities were being established, Those present, however, did represent a good cross section of consumer and provider groups, , RECOMMENDATION: The site visitors recommend that the Region be allowed | to go operational and believe that by doing so under specific guidance and advice from RMPS, the program will be greatly strengthened, Therefore, approval is recommended for three years: with the following considerations: 1) the Region obtain the services of an outside consultant(s) to examine and assess the organization structure Nassau-Suffolk RiP = 18 - and operating procedures with specific attention directed toward the CHP-RMP relationships; 2} the Reeion address the concerns of the mae a visitors; 3} the second year continuation application be reviewed by Committee end Council and include a site visit; and 4) that the level of funding be increased if significant progress is achieved during the first operetional year. For core activities, the site visitors recommend epproval of the amounts “requested as follows: OL . 02 03 $451,755 $490,408 $530,043 For eleven projects, $1,015,456 is requested the first year, $771,087 the second year, $689,636 the third year and $72,448 the fourth, A reduced amount is recommended each year for three years at one of three levels as follows: MAXIMUM MEDIUM MINIMUM $423,000 $378 ,000 $326,000 Therefore, the total for core and projects is recommended at one of three levels as follows: OL 02 03 MAXIMUM $874,755 $913,408 $953,043 MEDIUM 829,755 868,408 906 ,043 MINIMUM 777,755 816,408 856,043 (A Privileged Communication) REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL GRANT APPLICATION NEBRASKA REGIONAL MEDICAL PROGRAM RM 00068 5/71 Nebraska State Medical Association April 1971 Review Committee 1902 First National Bank Building Lincoln, Nebraska 68508 Program Coordinator: Harold 8. Morgan, M.D. REQUEST: This is an application for status as a new Regional Medical Program, to serve Nebraska. Requested (3 years beginning July 1, 1971): Projects lst Year 2nd Year 3rd Year TOTAL Core $394,670 $432,247 $440,653 $1,267,570 #1-Coronary Care 195,174 189,562 -0- 384,736 Training #2-Communications Facility 130,983 133,981 -0- 264,964 #3-Mobile Cancer Detection Unit 129,293 133,801 -0- 263,094 Direct Costs 850,120 889,591 $440,653 2,180,364 Indirect Costs 179,104 187,925 98,042 465,071 TOTAL $1,029,224 $1,077,516 $538,695 $2,645,435 FISCAL INFORMATION: This region is currently part of the Nebraska/South Dakota Regional Medical Program which was funded in the total amount $1,583,391 for core and three projects a period of 18 months, ending June 30,1970. Based on recent budgets for the last six months, the current annual level of support is as follows: Projects Direct Costs Indirect Costs. Total Nebraska $790,070 $165,424 $955,494 Core & 3 Projects” South Dakota $210,430 $51,916 $262,346 Core & part of Coronary Care Project Total $1,000,500 $217,340. $1,217,840 ‘Nebraska ; Regional Medical Program ~2- RM 00068 5/71 Attachments include "Pundirig Summary" and "Current Annual Level of Support", — both for the Nebraska-South Dakota REgional Medical Program. , South Dakota's planning application for a separate RMP was. reviewed by the February 1971 Council. Council recommended approval in the amount $379,500 d.c.o. for the first year ($259,500 for core and $120,000 for South Dakota's part of the Coronary Care project for one year only) with a level of core support $313,000 the second year and $376,000 the third year. GROGRAPHY AND DEMOGRAPHY : Chadron ® e Crawford Norfolk . . “Scottsbluff . North Platte Sidney Platte River Grand Is. Lincoln Hastings ® & Mc Cook @ Red Cloud Beatrice ® . s Nebraska, encompassing 76,712 square miles, is bordered on the north by South Dakota, to the west by Montana, Wyoming and Colorado, to the south by Kansas and to the east by Iowa and Missouri. Some characteristics of ‘the 1.5 million inhabitants are: 54% urban, 98% white and 30.2 years median age. Mortality rates per 100,000 are 385 for heart diseases, 161 for cancer, 128 for CNS vascular lesions and 24.4 for kidney diseases. Health facilities include Creighton University School of Medicine, the University of Nebraska College of Medicine, 9 schools of medical technology, 8 schools of X-ray technology, .1 school of cytotechnology, 14 schools of nursing (R.N.) and 4 schools of practical and vocational nursing. According to the Journal of the American Hospital Association, Nebraska has approximately 116 registered hospitals with 12,700 beds. Of these only about 48 have more than 50 beds, 24 have more than 100 beds and 19 more than 200. Of the 14 teaching hospitals, all in Lincoln and Omaha, 9 are major teaching affiliates of the two medical schools. Nebraska Regional Medical Program -3- RM 00068 5/71 Within Nebraska, there are 1,683 M.D.s (118/100,000), 61 D.0.s (41/100,000) and 4,653 active nurses (288/100,000). BACKGROUND: 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 in planning and the apparent cumbersome administrative framework. The Nebraska-South Dakota Regional Medieal Program was initally approved for two years of planning beginning January 1, 1967. A site visit was made in September 1968 to assess the Region's capability for operational status (core and four projects). The site visitors observed that 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. Coopera- tive 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 ‘partici- pation by Nebraska physicians, but much less involvement of South Dakota physicians. It was apparent 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 regionali- zation. It was also agreed that continued development of the Region would depend upon the initiation of some operational projects to provide visi- bility and a focal point for the high degree of enthusiasm displayed. In view of the site visitor's 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. The Region applied for support for four operational projects in May 1969. A site visit followed in June 1969 to assess progress 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 representation was broadened to include minority group representation, volunteer health organizations and nurees (70 RAG members, 35 from each state). South Dakota, which previously was less enthusiastic about joiniwg with Nebraska as a Region, appeared to have adjusted and was Nebraska . Regional Medical Program -4- RM 00068 5/71 participating on a more equal basis. The three medical schools. continued to maintain cooperative relationships. Planning also seemed to be on a more sdund 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 medical centers. Staff discussed this with the Region representatives in negotiating the award, emphasizing the need for real program outreach - not simply representation on various committees. The Region received an award 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 withdraw from the current two-state RMP and establish its own Region. Subsequent dialogue between RMPS staff, Dr. Hayes, and the Region Program Coordinator led. 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) 1£ South Dakota still desired separation, obtain clarification and elaboration of their draft proposal, which was very general and inadequate; and (3) provide appropriate 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. South Dakota's intent to separate became crystal clear and Nebraska seemed ready to acquiesce. RMPS staff reactions to South Dakota's draft application were discussed in detail. The July 1970 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. Upon receipt of South Dakota's formal application dated July 22, 1970, the applicant was advised that the issue of separation had to be taken up by. the November 1970 National Advisory Council following a visit by two of its members. They were advised that the application would then be processed through the regular review process, Review Committee in January 1971, and final consideration by the February 1971 Council. Nebraska Regional Medical Program -5- RM 00068 5/71 Because of the proposed division of the two states, a supplemental application dated July 27, 1970 from Nebraska-South Dakota RMP for $4,616,825 support of 5 new projects for 3 years was returned. On the basis of the visit October 27, 1970 by two of its members, the November 1970 Council approved the separation. The report of the visit is appended. 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 was extended for six months until June 30, 1971 at the current level of support. The February 1971 Council recommended approval of South Dakota's planning application for three years including support of their part of the coronary care project for one year. An award will probably be effective July 1, 1971 subject to funding restraints. PRESENT APPLICATION: Support is requested for core for three years and for the continuation of three projects for two years. GOALS : "I. To support programs at preventing the development of illness due to Heart, Cancer, Stroke, Kidney and Other Related Diseases. II. To support the design, of better programs for health care of the patient in his own community with reference to the diseases." OBJECTIVES : "I. To design better methods for the exchange of health care data. II. To develop research in training and demonstrations of patient care and to support more effective methods of the delivery of health care. III. To promote regionalization and cooperative arrangements as means of reducing health care costs. IV. To work with areawide health councils and other health planning _agencies to develop programs necessary to meet, provide or ameliorate the determined health care needs of the community. V. To improve and update the knowledge and skills of existing community health practitioners through various techniques of continuing education; training courses, demonstration programs, seminars, traveling clinics and access to addio visual communication systems. , Nebraska . Regional Medical Program -6- RM. 00068 5/71 VL. To encourage hospitals and nursing homes to. join in programs of continuing education for in-service personnel in order that these members of the health team be brought up-to-date on the latest techniques used in nursing care of patients with heart disease, cancer, stroke, kidney disease and other related diseases." PRIORITIES 1971: " I, Continuing education to be the primary activity. Il. Development of education programs in community hospitals. III. Improve communications and coordination with other health organizations. IV. Assist in all possible manner, efforts of organizations, in- stitutions and medical centers to develop a comprehensive program for the prevention, early diagnosis and treatment of renal . disease." ORGANIZATION: The application includes a list of current RAG composed of thirty-five members. However, Nebraska has revised the by-laws. A new roster of members (RAG, Officers, Executive Committee and Finance Committee) is to be provided prior to the April 1971 site visit. The President of the Nebraska State Medical Association presently serves as Chairman of the RAG. . The by-laws, approved by the RAG January 27, 1971, provides for the election of officers by the RAG; chairman, vice chairman and secretary by the RAG. There is also a provision for an Executive Committee and Budget and Finance Committee. EVALUATION: The brief description of methods for program and evaluation speaks only to rating proposals. , CORE: The request for core budget for personnel in the Requested Central Office, Creighton University School of First Year Medicine, and the University of Nebraska has increased $394,670 about 19%. The Central Office budget portion includes 12 professionals (10at 100%, 1 at 20% and 1 at 50%) and 6 full-time secretaries. Unfilled positions (5) include, a program planner, a nurse, a health educator, statistician and a secretary. Central Office personnel includes project management personnel of the Coronary Care Communications projects, six positions at approximately $103,700. This transfer was made as a result of the RMPS management assessment visit February 1970. Core staff at the Nebraska College of Medicine ($44,783) and Creighton ($40,448) consists of two professionals and one secretary at each of the two medical schools. Other significant budget items are supplées at $24,200 and travel at $41,000. Nebraska ; Regional Medical Program -7- RM 00068 5/71 The foci of core activities has been the three operational projects. Other activities have included a contract with the Continuing Education Department of the University of Nebraska to provide a series of telephone conferences in the two states and circuit courses. Nineteen telephone network conferences were conducted for physicians: and nurses Juhe 18 through December 15, 1970. Two additional conferences were planned, but were cancelled because of poor reception. Nine con- ferences reached a total audience of 471 physicians, an average of 52 per conference. Ten conferences reached a total audience of 1,144 nurses, an average 114 per conference. Post conference evaluation in terms of subject interest broadcast quality, usefulness of information, was done’ by written inquiry. Evaluation response ranged from 28% to 80% (average 59%). Six circuit courses were conducted in different communities in Nebraska and South Dakota with a total audience of 394 (average attendance 66). Evaluation of two courses dealing with care of terminal patients, indicated courses effectiveness in behavorial change. Televised continuing education for dentists is under study. One program sponsored by the Region and the South Dakota Dental Association was scheduled to be aired over the educational T.V. networks in both states. Some effort has been made to establish a closer relationship, with CHP A & B agencies, including a workshop initiated by the N-SRMP. A series of joint conferences are being considered. Sub-regions are to be developed where CHP agencies exist. Two "B" agencies are now in the planning stage and two are operational. The core staff at Creighton are assisting the planning for that institution's involvement in the Inner City Health Delivery Services, including the development of health centers. This program includes involvement with the Omaha Department of Health, the CHP B agency, and the Greater Omaha Community Action Program. These personnel were also involved in the dental T.V. program; a survey of heart disease in children; and organizing a four-day seminar on health careers management. The core staff at the University of Nebraska are interested in developing a curriculum for allied health training at the University. These personnel also assist the University's component of the coronary care project. They are also responsible for the coordination of planning a Kidney disease program. Second year: $432,247 Third Year: $440,653 Nebraska Regional Medical Program -8- RM 00068 5/71 Project #1 - Coronary Care Training-This application . Requested Lo is for continuing support of Nebraska's First Year part of the project for two years. This project, $195,174 now in its first year, was approved for three years, $443,647 the first year, $313,138 the second, and $367,871 the third. As a result of study by the task force on heart disease, improved care for acute myocardial infarction patients was given the high priority. As a result, this project proposed coronary care training for physicians, nurses and medical technicians in the Region, and to offer community hospitals technical assistance in maintaining equipment and establishing _an information service. Its design was to offer the training programs in several locations and by several modes to provide maximum access. to hospitals remote from metropolitan medical centers. Thesproject was to have the potential to train 220 physicians, 330 nurses and 12 technicians annually. The present program represents the cooperative efforts of six institutions as follows: Bryan Memorial Hospital at Lincoln, Creighton University School of Medicine at Omaha, University of Nebraska College of Medicine at Omaha, University of South Dakota, Vermillion, S.D., St. John's McNamara Hospital at Rapid City, S.D., and Sioux Valley Hospital at Sioux Falls, S.D. According to current revised budgets for the last six months of the current eighteen-month period, the current annual level of support for the three institutions in South Dakota is $118,884 d.c.o. and $194,260 for the three in Nebraska. South Dakota Regional Medical Program has been approved for support of their part of this project at $120,000 for one year. The award, subject to fiscal restraints, will probably be issued to begin June 1, 1971. Reasons for the slow start are cited as lateness in the award and tooling up. Fourteen 4-week courses were conducted for 251 nurses in their place of residence. -Evening courses reached 73 nurses. The ROCOM system supplemented by physician lectures was rotated among 5 community hospitals for 61 nurses. Another program including a physiological and phar- maceutical workshop were conducted in 12 hospitals for 226 R.N.‘'s and 40 physicians. Five 2-day refresher courses were held for 174 coronary. care nurses. Five technician courses were attended by 23. Two equipment workshops were held in different locations for hospital personnel were attended by more than 70 engineers, nurses and technicians from 17 hospitals. 148 physicians participated in fourteen 2-day seminars. Project personnel visited 70 of (70%) Nebraska hospitals and 46 (70%) of those in South Dakota. ROCOM teaching packages have been delivered to 18 locations, 9 in each state and 667 have been recipients of this training. Education by pre and post testing have proven to be of questionable value. Evahuation of trainees performance six months after training is now being done. Second year; $189,562 Third year: -0- Nebraska Regional Medical Program -9- RM 00068 5/71 Project #2 - Communications Facility- This project, Requested now in its first year, was originally First Year approved for three years, $132,715 the first year, $130,983 $132,715 the second and $171,390 the third. South Dakota has indicated no interest in trying to divide the support of this project. The program is to develop a communications facility located in Omaha involving the facilities and resources of the local educational institutions: Creighton University, University of Nebraska Medical College, University of Nebraska and several teaching hospitals. The facility, as proposed, is to consist of four components: 1. a telephone access information system accessible to medical personnel via a WATS line, a medical tape library service and drug information; 2. resource for referrals; 3. information resource for information and assistance for instructing materials; 4. audio-visual equipment supply and advice. The program, under the guidance of the project administrator, is operated 24 hours per day, 7 days a week. The project line switch board connects Nebraska, South Dakota, Iowa and Kansas through a series of WATS lines. The drug information service received 390 calls. Study of drug adverse reaction reports is a secondary objective. The media library staff have accumulated some. library material and have visited 76% of the hospitals to assist in the development of in-service training programs. A tape library located at the Nebraska 'College of Medicine, became operational in January 1971 and will provide the service to practitioners in Nebraska, South Dakota and Iowa. The project library now has 100 tapes owned by the University of Nebraska and 90 owned by the N-SDRMP. Iowa is to contribute 150 tapes. Second Year: $133,981 Third Year: -0- Project #3 - Mobile Cancer Detection Unit Now in its Requested first year, this project was approved for | First Year three years, $134,739 the first year, $128,739 the $129,293 second and third years. The project proposed to provide an improved cancer detection program for the low socio-economic families of Omaha served by the clinics of the two medical schools. The mobile unit is to augment the existing clinic services, and is also to be available to rural concentrations of American Indians. Screening procedures include: oral, colon rectal, breast and uterine. A study is to be conducted to evaluate the effectiveness of the simple screening tests and the automated history Nebraska Regional Medical Program -10- _ RM 00068 5/71 system. The Communications Project is to provide backup. on the question- | answer phase of the activity. A cancer detection education program at the U.N. was also planned. The mobile unit is reported to be udder construction as of January 17, 1971 with delivery expected soon. Two nurses, 4 sociologist, a biostatician, and a secretary have been employed. Equipment including a mammography unit, dental chair amd examining tables has been acquired. The socio- logist has done some work towards proposed service for Indians. One nurse requiring additional skills was given training under the direction of the Chairman of the Department of OB-Gyn, Kansas University Medical Center. Project principals visited the Kaiser Permanent Multiphasic Screening Unit in Oakland, California. Projected scope of work including caseload is not specifically stated. Second year: $133,801 Third Year: -0- @ Nebraska Regional Medical Program -11- RM 00068 5/71.1 NEBRASKA-SOUTH DAKOTA FUNDING SUMMARY RM 00047 - PLANNING Council - November 1966 November 1968 Site Visit ~ September 1968 lst 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 ane 1/ The Region was initially approved and funded for two years of planning. Unon review of the three-year operational application, the Review Committee and Council concurred with the site visitors that operational status was rremature. Accordingly, the three-year operational application was funded as a renewal planning grant carrying commitments (d.c.o.) $350,239 the second year and $738,832 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 préor to January 1, 1972. @ . The renewal award for the third year of planning included $107,880 ($102,520 direct costa and $5,360 indirect costs) for one year additional planning of two rrojects, #2 - Audio Visual Continuing Education Services and #3 - Coronary Care Program. Project #4 - Stroke Rehabilitation Technician Training - was disapproved. Nebraska Regional Medical Program “12> — RM 00068 5/71 OPERATIONAL . ~ >. 141/70 = 12/31/72 Council ~ 1969 August and December Site Visit - 1969 June Direct Costs Approved Approved Period Funded _ Future Level Core af 2years = (OL): $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 | ns (03). 171,390 #3 - Stroke Education Approved - Not Funded #4 - Neoplastic Disease _ 3 years ~ (01) 134,739 (02) 128,739 — . (03) 128,739 TOTALS as of December 28, 1970 ——--& (01) $1,024,239 (02) $1,000,495 (03) $668,000 Note* Ol year award includes authorized use of carryover $23,744 ($17,744 Core and $6,000 mobile unit #4) Approved - Not Funded #3 -. Stroke Education ol 02 03. ~—Ss«=s Total Direct Costs $187, 350 $187 , 350 $187,350 $562,050 TOTALS as of December 29, 1970 (01) $1,312,992 (02) -0- (03) -0- The 61 award was amended December 29, 1970 to extend the period for ed six months with additional funds. No future commitments were made oes because of the decision to dissolve the current bi-state structure and form two separate regions. OTe soronary ore roject sommuni = ‘ations 'roject vancer fobile NEBRASKA - SOUTH DAKOTA REGIONAL MEDICAL PROGRAM - RM 00047 Current Annual - Level of Support Based on Budgets for the Period 1/1/71-6/30/71 Nebraska So. Dakota Total Direct Ind. Total Direct Ind, Total. ‘Direct Ind, Total Costs Costs Costs Costs Costs Costs Costs Costs Costs $334,358 $77 ,430 $411,788 $91,546 $24,006 $115,552 $425,904 $101,436 $527,340 194 ,260 34,896 229,156 118 ,884 27,910 146,794 313,144 62,806 375,950 132,714 13,834 146 , 548 132,714 13,834 146,548 . 128,738 39,264 168 ,002 128,738 39,264 168 ,002 $790 ,070 $165,424 $955,494 $210,430 $51,916 $262,346 $1,000,500 $217,340 $1,217,840 -€I- South Dakota RMP Site Visit —14- Date: October Piace: School] RMPS Visitors: Personnel from RMPS Vist. to South Dakota ‘Vermillion, South Dakota 27, 1970 of Medicine, University of South Dakota (Vermillion) - Bruce Everist - National Advisory Council, RMPS Clark Millikan - National Advisory Council, RMPS 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 Ear] B. Scott, Ph.D., Professor of Anatomy, University of South fakota, 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, 20 per cent South Dakota RMP Site Visit , - 15 - Mr. G. Halter, SDRMP Staff,190 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 Dr. George W. Knabe, Jr., Dean, University of South Dakota, School of Medicine * General: The Nebraska-South Dakota Regional Medical Program apparently hepan amiably in 1966 with what appeared to be a rational approach to repionalization 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. , ?.. 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. .As South Dakotans see it, they were treated as country cousins, made to feel that they were lacking in sophistication, and therefore, havinp, to attempt to make up for this with sincerity, enthusiasm and dedication. 5. The Seuth Dakotans believe that there was inequity in the distribution of funds. 6, yer Winston-Salem G Sur! I S teat Yee ea Autonter 2 Magione city ¥2 ‘es > x pone ‘\ we | Ca OF ribnabirog sete ™ TENN \veeenton |” a aw 2 on aad a, r =. Oe ronom ay 7 Eafe’, | 4 . wath e ARLE DUNG - s o . ot = — — - . 7S re , Dgarsnon * Spruce | ound Lenore ra Mochwille Thomasvitte | High Point. 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Qo } a GC eg o ‘ a x } 2 i ’ | 3 i 1 i ~ Caemaweenee fete eo meh ee ek ee Pore erica een IEEE OE a ORES OEY ANG REAL SRE Sagar Nes pani A REAR RIMMER coh ata Ale a cAR AE A atok hae NDE AA ake = mata mane wm . ect he ee eee OR ne ami eM em nee ee ob one treteior Ant oht Toate pete 6 cee ine BO iy 68 tS hPa AIL ym nee “7 : . . : i. ‘ -AQ- . : oe ' ca jobpnmarepe ge ge ce perce eee ' wt i ‘a | { \ | ° if alinfolealsrloa perpen hala japaiayo rs : ‘ yo oN a ete w or : tale d ies tin feston ideo kata O[wr Op ovis: Seg feeb al dufcafo oO wthst ies fea (Ohta. sop 5 . ; teal wafer af RMP 12 Counties Cleveland | 20 Counties : micntano wn t " ASHLAND aggre VINTON CINCINNATI sciety | FORTSMOUTH anams ~ Ohio Valley RMP 14 Counties Overlap with Ohio State [ | County with LAWHENEE — wa or more Congressional Districts t ' yok MARION ae MARION HOLMES MORROW : a4 LS TUSC AFA HAS L KNOX ye i i 2 ! STEUBENVILLE wel abet SHOCTON i ; UNION DELAWARE annie Se , cosn Bi . ' — —feuraren 3 ; v7] po weeny | L. aan DaPAL CuaMra Gs pom Hn ee Wicrins | qT NEWARK oneney | FALE, wu, pea me t a, TU mane | TANESVHLE ° r aveeer eee Fakeia [ PhHHY b= ~ “ “me b _ ? pe | | 7 PICRAM AY | LANCASTER” | i MORGAN ij pa 3 FAVETIE _f lL —— , o MIDDLETOWN ST now mocnins 7 en wasnt ton ; BUTLER > 10, ATHENS, Ohid State RMP 61 Counties Columbus CHARACTER ES TICS Popubat bon hot inate Current Yoar of Uperations Current Funding ().¢.) Core Suppore Projects Requested Funding Next Year (.C.) Developmental Componei Facilities & K Medical School Professional Nursing, School Practical Nursing Training Allied Health Schools General Hospitals/Beds Number of SMSA Grantee Agency Fiscal Agent Regional Advisory Group: Number of Mewbers Number of Annual Meetings Profess3 Core Personne $ Major Conc Staff Review (See Individual Summaries for Details) erns of xPwo overlap arcas ~ one with Ohio Valley THREE RMPs 1N ONLO OHIO STATE (COLUMBUS ) 3,256,000 0g $977,793 ($533,245) ($440,548) $1,832,892 Requested one un bet ur 127/17,000 five* Ohio State University Ohic State University 34 three 14. full-time 3 part-time Minority & Consumer Representation Program Direction Affect of Grantee Impact KA(SMSA). Standard Metropolitan Statistical Area OUTO CYOLE DG } 1,260,000 02 $781,332 ($335,200) ($446,132) $1,324,519 Requested one 20 36/4 ,900 two Medical College of Chio at Toledo Medical College of Ohio at Toledo 50 four 7 full-time 5 part-time Weak Administration and Management Core Personnel Lack of RAG Involvement Program Outreach and one with West Virginia. NwB. OHIO (Cleveland) 4,109,000 G1 $690,187 ($445,250) ($244,937) $995,597 Not Requested one 2] 42 65/16 ,545 four NEORMP Case Western Reserve University 71 four 11 full-time 0 part-time Absence of Coordinator & Critical Staff Consumer Representation RAG/ Board Trustee Relationship REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) NORTHEAST OHIO REGIONAL RM 00064 5/71 MEDICAL PROGRAM April 1971 Review Committee 10525 Carnegie Avenue Cleveland, Ohio 44106 Program Coordinator: David Fishman, M.D. (Acting) This region currently is funded at $690,187 direct costs for its first operational year ending June 30, 1971. The O1 year award included indirect costs of $47,420, which represents an average indirect cost rate of approximately seven percent. The Region submits an anniversary application ‘which requests 02 year support as follows: LI. Continuation with committed monies of core and three ongoing activities. Ii. Funds for continuation of one ongoing activity for which no monies have been awarded -- it was initiated during the 01 year through rebudgeting. III. Supplemental core support. Iv. Funds for implementation of two new activities. A breakout of the 02 year and partial 03 and 04 year requests are included as pp. 12-14 of this document. Although no site visit to the NEORMP is scheduled, staff review of the continuation portion of this application highlighted certain areas of concern in which the Committee and Council reviewers may be interested. These are noted briefly below and discussed in more detail on pages7 - 9 of this summary. 1. The absence of a Coordinator and critical staff members. 2 Lack of significant consumer representatian throughout the regional committee structure, except for the newly reconstituted RAG. 3. Relationship between the Board of Trustees and the RAG and the question of where decision-making authority rests. NORTHEAST OHIO -2- | RM 00064 5/71 REGIONAL MEDICAL PROGRAM FUNDING HISTORY - (Planning Stage) | . 7 oo Funded : : Grant Year Period (direct costs) ‘ O1 1/68 - 6/69 (18 mos) $267,911 02 oO 7/69 - 6/70 $462,663 (Operational Program) a Funded Committed Grant Year Period (direct costs) (direct costs) 01 7/70 - 6/71 $690,187 1/ - 02 7/71 ~ 6/72 - $707,568 3 03 7/72 - 6/73 - $707, 568 1/ Based on a negotiated budget of $786,187 but adjusted to permit the use of $96,000 unobligated balance from the 02 planning year. 2/ Recently reduced from previous commitment of $786,187 because of RMPS fiscal constraints. GEOGRAPHY AND DEMOGRAPHY: The Northeast Ohio Region includes a 12 county area with a combined population of 4,100,000, and has a well- developed, efficient, and accessible transportation and communication systems. Five standard metropolitan service areas (Cleveland, Akron, Youngstown-Warren, Canton, and Lorain-Elyria) represent the major population centers. The Case Western Reserve University School of Medicine in Cleveland is the only medical school within the Region. Cleveland, as the largest population center, is regarded as the major center for ~ medical care, teaching, and research. In addition to the Medical School and its affiliated hospitals, Cleveland has a number of outstanding medical facilities. Each of the other major cities has large community hospitals with active postgraduate and continuing staff educational programs. There are 65 general hospitals in the area (excluding 10 osteopathic) which have a total of 16,545 beds. HISTORY: This program received its first planning grant in January 1968. The Region experienced initial difficulty in recruiting qualified personnel until Dr. Barry Decker was appointed coordinator in June of that year. Since no actual planning activities were undertaken during the first five months, the coordinator received approval for a six-month extension without additional funds. As a result, the 01 planning year covered an.18-month period ending June 30, 1969. Following the coordinator's appointment, appropriate staff was recruited NORTHEAST OHIO REGIONAL MEDICAL PROGRAM -3~ RM 00064 5/71 and the design of the organization and strategy completed. Initially the Region concentrated on developing a large volunteer organization of about 300 individuals to disseminate information. Data collection needs were identified and publications on health-related data were compiled and distributed. Strong ties with comprehensive health planning area-wide and state health planning agencies, and other institutions and agencies were developed. The second-year planning award included increased staff support and three feasibility studies in the areas of diabetes, libraries, and the development of a demonstration laser unit for intra-hospital television transmission. In February 1970 the Northeast Ohio Regional Medical Program received a pre-operational site visit. The site team and subsequent Committee and Council reviewers agreed that the Region had demonstrated capable leadership in developing cooperative relationships throughout the area and had involved large numbers of providers in the Committee and overall organizational structure, had established data collection mechanisms and a priority system, and had recognized the need for strengthening evaluation processes. Concern was expressed, however, that few consumers of health care were involved in the program and it was suggested that the Region seek ways to involve these individuals on both the Regional Advisory Group and the various committees. Of additional concern was the relationship of the 14-member Board of Trustees/Executive Committee with the Regional Advisory Group. It appeared that the actual responsibility of approval of projects and assigning of priorities was retained by the executive committee, which is self-perpetuating by virtue of appointing itself, and members of the RAG and various other committees. The site visitors thought this served to diminish the vitality of the RAG. It was recommended that these problems be remedied by developing a more democratic appointment system and returning responsibility for the review process to the RAG. It also was thought that the intricate priority system which had been developed might not provide the necessary objectivity. The operational application which the Region submitted, requested support for core and ten projects ( of which five were subsequently recommended for approval). An O01 operational year award for the support of core and three projects was made in June of 1970. A fourth activity subsequently was incorporated into the core budget, and a fifth funded through rebudgeting of basic grant funds. The Region's current distribution of funds is shown below: Core (including Organization for $445,250 University Cooperation in Health) #1 - Library Consulting Service 24,112 #2 - Nurse CCU. Training 79,844 #3 - Strep Culture 104,807 #7 - Stroke Rehabilitation Demonstration 36,174 $690,187 NORTHEAST OHIO REGLONAL MEDICAL PROGRAM -4- RM 00064 5/71 ORGANIZATION AND STRUCTURE: The grantee is a non-profit Ohio corporation which receives fiscal services from the ‘ Case Western Reserve University. The current organization structure of the Northeast Ohio kegional Medical Program consists of the following: 1. The Regional Advisory Group with 55 members meets quarterly to review policy,program and projects for submission to RMPS. Nominating Committees in each of the six subregional areas select representatives to serve on the RAG. 2. The Board of Trustees with 18 members meets on a monthly basis and maintains the dual responsibility of acting as the legal guardian of the RMP and as the Executive Committee of the RAG. The Board selects its membership from a slate prepared by a Nominating Committee of the RAG. 3. Categorical Committees (Heart, Cancer, Stroke, and Respiratory). 4. Problem Committees (Education, Service, and Data). 5. Subregional Area Committees (Central, Cuyahoga, Eastern Lorain, Northern, and Stark). 6. Numerous Subcommittees and Task Forces as determined by Committee Chairmen and the Board of Trustees. The Committee structure of this Region involves the participation of more than 350 people throughout the area. Subsequent to the February 1970 site visit and Committee/Council review, and in response to their concerns about the passivity of the RAG, its relationship to the Board of Trustees and the low level of consumer representation, the RAG appointed an ad hoc committee to racommend how it might better fulfill its advisory and approval functions and how the Region's administrative structure might be improved. The final report of this ad hoc committee has been accepted by the RAG and is included as a supplement to the anniversary application, along with a list of the reconstituted RAG. Briefly, the major changes which have been effected are: 1. The reduction of the RAG membership from 70 to 55, and the reduction of the number of automatic appointments to RAG from 58 to 10. The previous organization provided for the automatic inclusion on the RAG of all members of the Board of Trustees, all committee chairmen, and two additional members from each committee. 2. Greater diversification of RAG membership to provide for less physician and greater consumer and non~medical representation. 3. Changes in selection procedures for RAG and Board of Trustee members. NORTHEAST OHIO REGIONAL MEDICAL PROGRAM -5- RM 00064 5/71 4, Recommendation of the ad hoc committee that categorical committees be de-emphasized and more reliance placed on area committees. CORE: The core staff includes eleven full-time professional personnel. It does not include a Coordinator -- Dr. Decker resigned in September 1970, and program direction has been assumed by the Executive Committee of the Board of Trustees. This Committee also is conducting a search for a replacement coordinator. In addition to the Coordinator's position, there are four other professional slots unfilled. The majority of the core staff is physically located in the central offices in Cleveland, with reigonal offices in Youngstown and Akron . housing small contingents of core. During the past year, core staff has engaged in a plethora of activities, many the convenor/facilitator -/broker type, and many in cooperation with various agencies and institutions. These are described on pp. III-11 through III-27 of the application and shown on the chart on page 2 of this summary. Core staff also implemented the Organization for ‘ University Cooperation in Health (OUCH), which was approved as a separate project at the national level but subsequently initiated as a core activity. The Northeast Ohio Regional Medical Program sees its future as lying primarily in continuation and expansion of core staff activities and cooperating with existing programs rather than emphasizing project development. During the coming year core staff efforts will concentrate in the following areas: 1. A regional network of hospital-based Directors of Continuing - Education with RMP backup services in evaluation and continuing medical education. 2. A regional health data system as a service to other regional agencies involved in health planning. 3. A regional network of hospital-based "discharge planners" to the continuum of other medical services. 4. The planning, education, placement and evaluation of physician assistants in the hospital, inner-city and rural environments. 5. Developing relationships between consumer groups and provider elements to improve health services to the poor. REVIEW PROCESS: Projects are initiated by any of the Northeast Ohio RMP committees or any non-profit agency or health organization. The core staff provides assistance in the development of specific projects. All grant requests are reviewed initially by staff to insure inclusion of the necessary information and to refer the requests to the appropriate committees. All projects are referred to the local area committees for opinions regarding local applicability. Core Suppor ted Activities of Northeast Ohio Regional Medical Program Categorized by Health Needs PRIORITY 1 PRIORITY 3 PRIORITY 2 PRIORTIY SCANT SOS TN ENT TIRGSNT ‘ IMPORTANT SIGNIFICANT PERTINENT Health Service Northeast Ohio RMP Prevention & Delivery Distribution Quality Neads of the Poor Organizational Coals Detection Of Disease © of Health Services or . Health Services Medical Services Akron Model Cicies Clevelaads West: Side Citizen's for Better Health Metropolitan . Eealth Planning Corporation Maltiohasic Screening in Trumbull County Health Educa- tion for Better Urilization of Services by Urban Poor | Ceatralized Data Processing for Lorain County Coordination of Ohio Regional “Medical Programs Health Data System with a.CHr Agency Regional Health Data System (with four CH? B agencies} Rehabilitation Needs (with CHP) Stroke ; Rehabilitation Demonstration Demonstration Need for Speech *> Therapists in Community. Hospitals Interagency Council on Smoking and Health Self-Instruction for Diabetics Development of Regional Tumor Registry OUCH Discharge Planning in Lorain County Respiratory and CE for Paramedicals HCIO CE. in Nursing Kicney & Renal Hospital Study Discharge Planning with Matropolitan Health Planning Corp. Raciation Therapy Guidelines (with Metropolitan Health Planning) . Pulmonary Work Eval- vation Clinic Coordination with Desartment of Coms unity Health Students from Univer- sity of Michigan, University of Cali- fornia and CWRU “ealth Careers Day Ohio Hospital Association Seninars Participation in Ad Hoc Committee on Medical Educa- tion Professional Education Progyams Expansion of Health Programs 4 at Youngstown State University troke Filmstriss NORTHEAS? OHIO REGIONAL MEDICAL PROGRAM RM 00064 5/71 Following review and modification, projects are submitted to the Board of Trustees for approval, priority rating, and referral to the Regional Advisory Group. , REGIONAL PRIORITIES: The current identified health needs of the Region and their priority ranking remain identical to those formulated and submitted in the original application for operational status a year ago. Each problem is classified on a scale of urgency (Urgent-4, Important-3, Significant-2, and Pertinent-1l) and this scale is used in the priority ranking by the Board of Trustees of the projects that go through the review cycle. 1. Immediate health service needs of the poor of the cities of Northeast Ohio (Priority 4-Urgent) 2. NEORMP organizational goals (Priority 4-Urgent) 3. Prevention and early detection of disease (Priority 3-Important) 4. Increase in the potential for the delivery of health services (Priority 3~Important) 5. Equalization of the distribution of health services (Priority 2-Significant) 6. Improvement of the quality of medical services (Priority 1-Pertinent) Forty percent of each project's numerical priority rank is determined by this scale of the urgency of the health problem which is addressed. The remaining 60% is calculated on factors of regionalization potential, estimated effect, probability of success, cost-benefits, adequacy of evaluation and probability of self-support. Included as page 8 of this summary is a chart showing the breakout by health need category of the activities for which funding is requested in this application. I. Continuation Commitment: Staff has reviewed the continuation portion of this application which requests committed support for core activities and three ongoing activities: #1 - Library Consulting Service, #2-Nurse CCU Training, and #3-Strep Culture. The Program Coordinator, Dr. Barry Decker, resigned in September 1970, and staff reviewers experienced great difficulty in evaluating this Region and its potential for the future in the absence of either a Coordinator or a Deputy Coordinator. There is no indication as to when a Coordinator will be found. In addition, positions for Directors of Evaluation, Research, and Communications are vacant. Although the descriptions of core staff activities are most impressive, the question of whether core will be able to maintain this momentum without Dr. Decker is moot. NORTHEAST OHIO REGIONAL MEDICAL PROGRAM ANNIVERSARY APPLICATION REQUEST CATEGORIZED BY HEALTH NEEDL/ , . PRIORITY PRIORITY 4 PRIORITY 3 3 . PRIQRTTY CORE URGENT IMPORTANT Significant) Pertinent ealth NEORMP _ |p ti &! Del Distr. , 1 Beatie Organiza- berection of pester ri ced of Health qual esy oF TOTAL _ Weeds of tional Goals|Disease Services | Services _ $191,601 / $95,347 . ‘ Library Service CONTINUATION $606,748 Strep _ [Nurse CCU Trg. $803,696 2/ with Core Culture OUCH (funded ~ Commitment : / from Core) _ with . Supplemental Funds ‘| $50,145 ; 50,145 ‘ Stroke Rehab. $91,756 Pulmonary Work 1 . $50,000 . Evaluation «© core : : . Discharge Plan. upplemen Health Careers : in Ohio . $141,756 (funded from Core Suppl.) JTOTAL REQUEST $656, 748 $95,347 -0- $50,145 $193,357 -0- -0- $995,597 x r- i/This chart includes only those activities for which funds specifically have been awarded or requested. It does not include numerous staff and core-supported activities which are outlined on pp. II-6 through II-8 of the applicatim and the chart on page 4 of this summary because of RMPS fiscal structure. : 2/The Region has requested the Council-approved level rather than the actual commitment of $786,187 . which has since been reduced to $707,568, NORTHEAST OHIO . REGIONAL MEDICAL PROGRAM ~9- RM 00064 5/71. Core activities during the past year have been varied and imaginative. Good working relationships with many other institutions and agencies are apparent, and substantial staff effort is spent in convening and facilitating activities. The real meat of the NEORMP lies in the realm of its core functions. In fact, the application states that core staff energies and funds can be used more efficiently and appropriately through cooperating with existing programs and developing several areas of obvious need rather than encouraging and submitting new projects for which funds are not likely to be forthcoming. The staff consensus was that the core dollars in this Region generally have been used wisely. The February 1970 site visitors expressed concern about the relationship of the Board of Trustees to the Regional Advisory Group, as well as the lack of consumer representation. Included as a supplement to the anniversary application is the Region's response. The RAG member- ship has been diversified and reconstituted and does, indeed, include much greater consumer and non-medical representation. However, this diversification has not extended to the extensive committee structure, the membership of which is virtually entirely provider-oriented, and primarily physicians. Also, changes have been made in selection procedures for RAG and Board of Trustee members, but the functions of these groups seem not to have been altered. Staff had serious concerns as to whether the decision-making responsibility in this Region rested with the Board of Trustees (an appendage of the grantee institution) or with the Regional Advisory Group. RMPS should assist NEORMP in developing an organizational structure in which the RAG can operate without a watchdog. The extent to which there is coordination among the four Ohio RMP's is always a question. Staff recommended an award of $707,568 (reduction of the previous commitment of $786,187 by $78,619 because of RMPS fiscal stringencies) for 02 year continuation of core and three discrete projects, and that its concerns should be relayed to the Region with an offerof any possible assistance. II. Continuation with Supplemental Funds Requested Project #7 - Stroke Rehabilitation Demonstration. This project Second Year was included in the initial operational request, $50,145 but the Committee/Council could not approve it, primarily because of its lack of clarity and because it seemed mainly to support patient services. However, the Region expressed such deep concern over the rejection of this activity that RMPS agreed to consider a revised proposal. The Region's feeling was that this project represented an activity outside of Cleveland and a sincere attmept to provide better coordinated care of stroke patients. The project was considered extremely important to the regionalization process. July 1970 Council reviewed the revised proposal and recommended approval in the time and amount requested. Althaugh no funds were awarded for the conduct of this project, the Region elected to initiate it by rebudgeting monies from core. NORTHEAST OHIO REGIONAL MEDICAL PROGRAM -10- RM 00064 5/71 The present application requests money for the second and third years. The revised proposal stated that efforts would be made to have this. | | activity self-supporting at the end of the third year. | . The objectives of the program include establishment of a comprehensive ambulatory stroke care program and of a replicable model of this ‘type of care in a non-hospital setting, as well as a demonstration to increase public. and medical awareness of the benefits. Since October 1970 when the activity was implemented, three new people have been hired, neurology and orthopedic clinics have been established, all of the hospitals and medical societies of the three-county area have been informed, and an increasing number of stroke patients is being served. Third Year: $26,076 Requested First Year ILI. Supplemental Core Support: Subcontract funds are requested $50,000 for NEORMP's contribution to the | program Health Careers in Ohio, to which three Ohio RMP's are contributing. It is being conducted under the auspices of the Ohio State RMP and is centered in Columbus. Applications inthe current review cycle request funding for the next year as follows: Ohio State RMP $145,000 North East Ohio RMP 50,000 North West Ohio RMP 25,000 $220 ,000 Ohio Valley RMP contributed $5,000 to this activity last year, but has since withdrawn its support. 7 Second Year: $50,000 Third Year: $50,000 Iv. New Activities: Each of these two projects addresses itself to the problem of improved delivery of health services, and each received from the Board of Trustees and the RAG a priority ranking of three, on a five point scale. Requested Project #11 - Pulmonary Work Evaluation Clinic. This proposal would First Year establish a clinic which would accept from physicians $37,353 throughout the region referrals of patients with diagnosed or suspected pulmonary problems; evaluate the degree of impairment in relation to his ability to work; recommend to the physician a comprehensive plan of approach to treatment and rehabilitation. The clinic would operate one day per week staffed by a medical team consisting of a clinic director, technicians, vocational counselor, social worker, and in selected cases, a psychiatrist. After a study of the patient, the staff would confer to reach basic recommendations, especially as to his ability to hold a job and function in the community. This would ie! be reported in detail to the referring physician. Second Year: $27,909 Third Year: $27,909 NORTHEAST OHIO REGIONAL MEDICAL PROGRAM -l- RM 00064 5/71 Requested Project #12 - Discharge Planning for Continuity of Care, First Year Lorain County. The aim of this project is to $54,403 establish a fully cooperative Discharge Planning Program under the County Health Department which will insure adequate care for the continuing health needs of patients in all hospitals in Lorain County. This program will develop slowly; starting with one large hospital the first year, and expanding to five smaller hospitals and complete county-wide coverage by the end of the second year. Second Year $63,327 _GRB/RMPS 3/11/71 ssaton . Northeastern Ohio vOLE TORE 0008 5/7007 ™ "Anniversary Review) ~~ 605,748 606.748 30,337. 637,085 Core Supplement _ - 50,000 50,000 9 = +7 50,000 #1 - Hospital Library ” oe ___... Cousulting Services 9 31,243. _ 31, 243 5,769 37,012 #2 + Nurse CCU Training 70,358 70,358 - 5,429 75,787 Rieunatic Fever Prev. ° — ~ ~ ___ #3 = by Serep. Cul. Prog.” 95,347 95,347. . 12,395 107, 742 Sxroks Rehab. Dea. —— #7 = Feaject _ 56,145 50,145 ° 4,014 54,159 vuluonary Work : . Sem me mee meee eee ___ file Evaly uation Clinic : 37,353 37,353 - - O08 37,353. } . women me Fee = _. #12~ Discharge | Planning : 54,403 54,403 ° -0- 34, 403 TOTAt, 853,841 — 141,756" 995,597 . 57,944 1,053,547 GRE 2/8/71 4 » Nb Ji ~ « © @ : pretoex Northeastern Ohio © ‘ CYCLD RN 00064 “S/7T ANTAXOUT CP REQUEST___ 03 ___PEatoD ~ Gnniversary Review) ~ “ConTiNuING = PREVIOUSLY ACEINITINS RENEWAL APPR/UNTUN. “AS “DIRECT INDIRECT TOTAL : 0. 50,000 . 50,000 -0-= 56,009 Oe \ -0- ‘ -0- 26,076 | | 96076 =. «2,108 S28, 184 : 27,909. 27,909 = 0= * 27,909 b 63,327: 63,327 -=0- . 63,327 26,076 141,236 167,312 . 2,108 169,420 G2B. 2/9/71 BREAKOUT CF REQUEST —4_. PERTOD ' Northeast Ohio RN 00064 5/71 “TNENTIFICATION 1 CONTINUING Hi PREVIOUSL NEW : 5 {* ALL YEARS \ ALL Yhans 4 cr component | ACTIVITIES | RENEWAL | APPR, /UNEWN, ACTIVITIES| DIRECT | INDIRECT! TOTAL |. DIRECT | TOIAL ; ; " im i Core | i} 606,748 | 637,085 | - . vy _ ~ Core Supp. 50,000 50,000 | ~0- | 50,000 |' 150,600; 150,000 jt } 31,243 | 37,022 2 |: 70,358 | 75,787 #3 . | |; 95,347 | 107,742 j mi } ~ #7 “| [i 76,221 | 82,343- T. : oT, £1 ! | 27,909 27,909 | = 0- 27,909 |} 93,171 § 93,27b #12" 7 j' 147,730 £117,730 = i qT . . { t a) hl i | | 4 nk | i 1 oye ti i i 7 “ T ri 7 " men | ; i | | { i i : | - : : : i : | | | 7 i | aH . ; : : it : : | i. | . J ii i : - | 1 1 : i i ‘ e ; i 1 ‘ : | \ : . i vt , : | i : | | | | : | \ . i ti 4 ‘ { ! i TOTAL, | | 77,909 : 77,909 | 77,909 11,240,818 | 1,300,670 i . ' " : ! at , \ t t | | sk Od oan 2/9/74. | ~To AUR ee we tt Northwest Ohio RM 00063 Ohio State RM. 00022 STAFF OBSERVATION OHTO REGIONAL MEDICAL PROGRAMS Health Careers in Ohio Request: Three Ohio Regional Medical Programs have requests in this review cycle for support of a tri~regional program --.. Health Careers in Ohio. The program is centered in Columbus, Ohio, under the aegis of the Ohio State RMP, and a centralized educational information center has been established. Other activities which are in various stages of development include: An inventory of training and continuing education offerings. A student referral service. Programs for students in secondary schools, colleges, and universities. Training programs for educators in colleges, junior and senior high schools, and graduate students. Coordination of new health careers educational offerings and assistance in developing programs. . Pre-professional college program advisor and student programs. Establishment and coordination of action and resource health manpower career programs. Military Service Directed Into Health Careers (MEDIHC)- referral service. Evaluation and analysis of the delivery of health services as they concern health manpower and careers in the health field. Elaboration on these aspects of the. program can be found on pp. 58-61 of the Ohio State RMP application. The total funding which is requested for the coming year for this program is $220,000. The amounts which the three RMPs are requesting fe) 4 0 Ohio State RMP $145,000 Northeast Ohio RMP 50,000 Northwest Ohio RMP 25,000 The Ohio Valiey RMP contsibuted $5,000 to this activity last year but has since withdrawn ite upper t. RMPS Policy: The new RAPS policy on health careers recruitment precludes the use of grant funds for direct operational grant support of health careers recruitment projects, although the policy still permits the use of core staff aud planning monies to stimulate cooperative efforts between professional associations, clinical resources, educational institutions and other eppropriate agenctes to provide new opportunities for recrultment into health careers. The that this $220,006 request exceeds the bounds opinion of RMPS staff is of permissible support. (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE NORTHEAST OHIO REGIONAL MEDICAL PROGRAMS RM 00064 5/71 © FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: That this Region be funded at its committed level for one additional year. CONTINUATION COMMITMENT _Year_ Request , Recommendation ° 02 $803,696 1/ $786,187 2/ 03 7 | - 04 ee —_—— TOTAL $803,696 $786,187 SUPPLEMENTAL SUPPORT Year Request Recommendation 02 $191,901 -0- 03 167,312 oo ~0- _ 04 77,909 a, -0- TOTAL $437,122 -0- TOTAL ANNIVERSARY REQUEST Year Request Recommendation 02 $995,597 $786,187 2/ 03 - 167,312 -0- 04 77,909 ~0- TOTAL $1,240,818 . $786,187 1/ Region requested more than its 02 year commitment. 2/ $786,187 is the original commitment for these activities. The new reduced commitment due to RMPS fiscal constraints is $691,845. CRITIQUE: The over-riding problem presented by this application and pondered by the Committee concerned the basic viability of the Northeast Ohio area as a Regional Medical Program. Some of the specific questions raised in this regard were: 1. Little apparent relationship between Regional goals and the activities which were supported. 2. The absence of a Coordinator and critical staff members (Directors of Evaluation, Research and Communications) and the question of whether Dr. Decker, the previous Coordinator, was the driving force behind most Regional accomplishments to date. NORTHEAST OHIO RMP A 3. Generally unimaginative project activities. 4. Although the Cleveland CHP-B agency is one of the largest in the ‘country, NEORMP relationships with that agency appear not to be as extensive or fully developed as desirable. 5. The fragmentation of the State among the Northeast Ohio, Northwest Ohio, and Ohio State Regional Medical Programs. In view of the above points, the staff concerns listed on page one of the yellow summary and the question of the basic viability of this Region (and parallel problems in the Northwest Ohio and Ohio State Regional Medical Programs), the consensus was that the NEORMP should be supported for one additional year at its committed level, with similar holding actions being taken for NWO and OS RMPS. Each of the three Regions should receive a site visit to concentrate on that program's problems, strengths, and weaknesses. After these three information-gathering visits, a second-stage consultative visit should include the RAG chairmen, Coordinators, sponsoring institution representatives, and other officials of each program to discuss amalgamation of the programs. The one year continuation of the three separate RMPs, then, is viewed by the Review Committee only as an interim step toward the unification of Ohio. Continuation Commitment: Continuation funds were requested for Core and three ongoing activities (Library Consulting Service, Nurse CCU Training, and the Strep Culture). The Review Committee agreed that the commitment of $786,187* should be recommended for one additional year to support the conduct of these activities and other approved projects into which the Region chooses to rebudget, within this level of funding. Supplemental Support: Supplemental funding was requested for the following: Continuation of Stroke Rehabilitation Demonstration project which has been initiated during the 01 year through rebudgeting of funds. Although no additional funds were recommended for the continuation of this project, the Region is not prohibited from exercising its rebudgeting authority for its continuation. Supplemental Core support for NEORMP's contribution to the program Health Careers in Ohio. In view of the staff opinion that expansion of this program exceeds the bounds of permissible RMPS support, the Review Committee recommended disapproval supplemental monies for its expansion. Supplemental support for the initiation of two new activities: Pulmonary Work Evaluation Clinic and Discharge Planning for * Recently reduced to $691,845 due to RMPS financial restrictions _2- RM 00064 5/71 . “ NUKLHEASL URLU Kr ~ HY UVUU0O4E D//l which the NEORMP is experiencing (even though the Discharge Planning proposal was considered by some to represent the most imaginative project in the application) the Review Committee could recommend no additional funds for the initiation of these new projects. The Region is not prohibited, however, from beginning the activities through rebudgeting if it chooses. @ Continuity of Care. Considering the enumerated problems GRB/RMP 4/20/71 na) ww (A Privileged Communication) REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION NORTHWESTERN OHIO RM 00063 5/71 REGIONAL MEDICAL PROGRAM April 1971 -Review Committee 1600 Madison Avenue Toledo, Ohio 43624 Program Coordinator: C. Robert Tittle, Jr., M.D. This Region currently is funded at $781,332 direct costs for its second operational year ending June 30, 1971. The 02 year award included indirect costs of $219,773, which represents an average indirect cost rate of approximately 28 percent. The Region submits an anniversary application which requests 03 year support of $1,324,519, as follows: I. Continuation with committed monies of six ongoing activities. Il. Renewal of core support plus supplemental core support for contribution to an inter-regional health careers program. III. Activation of two previously approved but unfunded activities. IV. Initiation of three new activities. V.. Developmental Component A breakout of the 03 year and partial 04 and 05 year requests is included as pp.l1-l30f this document. Although no site visit to the NWORMP is scheduled, staff review of the continuation portion of this application highlighted items of concern in which Committee and Council reviewers may be interested. Many of these are unresolved problems which were identified by the May 1970 site visitors and the subsequent Management Assessment Team: 1. A lack of strong leadership in the administration and management of the region. This weakness is demonstrated by: a. Inadequate core staff input into RMP activities. b. Core staff functions, responsibilities, and lines of authority not being defined or delineated. c. Project personnel headquartered in the Region's central ! - office being diverted to core staff functional activities. d. An apparent control of certain medical school faculty over the Region's day-to-day administrative decisions. e. Serious shortcoming in core input into the financial management of the Region. Northwestern Ohio Regional Medical Program -2- RM 00063 5/71 2, A lack of involvement of the RAG collectively in the overall planning of the program. Also, the Executive Board of the RAG appears to be far more involved in direct management decisions than is appropriate for a policy-making group. ew -3. Although core staff has been reorganized, certain specific personnel questions arise: a. No minorities are identified on core staff. b. Although the half-time position of Associate Coordinator for Planning has been changed to full-time Deputy Program Coordinator, his effectiveness in providing strong leadership in the management and administration of the Region has yet to be demonstrated. c. While one of the Region's major objectives is in the - area of continuing medical education, there is no core staff member identified who is responsible for this effort. 4. Little or no interchange of information among the various |. reference panel members to promote inter-categorical planning. 5. Program outreach appears to be concentrated in the Toledo area, with some involvement in the Lima and Sandusky areas, while the remainder of the Region appears to lie dormant. FUNDING HISTORY (Planning Stage) . Funded Grant Year Period (Direct Costs) Ol 1/68-12/68 $274,450 02 1/69-6/70 (18 mos.) - $471,337 1/ (Operational Stage) Grant Year - . Pertod Funded (Direct Costs) . Future Commitment ol 7/69-6/70 - $490,502 2 --- 02 - 7/70-6/71 $781,332 --- 03 7/71-6/72 -- $401,245 3/ 04 7/72-6/73 -- $20,830 1/ Includes core support for 01 operational year. 2/ Support for six operational projects - 01 year core included in 02 year planning award. 3/ Recently reduced from $445,827 due to RMPS fiscal constraints. Northwestern Ohio Regional Medical Program -3- RM 00063 5/71 tT ] The current financial breakout for this Region's 02 operation year ‘ is as follows: Core $335,200 : #i-Stroke Education Program 96,847 #2-Uterine Cancer Detection 94,268 #4~Coronary Care Training 161,517 #6-Action on Smoking & Health 30,021 #7-Dial Access Tape 42,649 #15-Ottawa County CE Council 20,830 $781,332 GEOGRAPHY AND DEMOGRAPHY The Northwest Ohio Regional Medical Program is comprised of 20 counties with an area of 8,635 square miles and a total population of approximately 1.4 million. It is an industrial area, with 90% of the employed population engaged in non-agricultural occupations. Approximately 75% of the Region's population is concentrated in urban areas and 92% of the population is white. Transportation facilities within the Region are adequate to assure prompt access to medical facilities, principally by Inter- state Highways and the Ohio Turnpike. Seven major railroads serve the Region, in addition to two major interstate buslines and four major airlines. There is a new medical school, the Medical College © of Ohio, located in Toledo. There are, as well 10 schools of nursing, seven of medical technology, 12 of radiologic technology and one of cytotechnology. The Region contains 36 general community hospitals with approximately 4900 beds. The Northwest Ohio RMP is joined to the south by the Ohio State RMP based in Columbus, and to the east by the Northeast Ohio RMP based in Cleveland. HISTORY This Region had a two-year planning phase during which time core staff was recruited (Dr. C. Robert Tittle, Jr. appointed as Coordinator) and planning and data collection studies carried out. As a result of the information compiled from these studies, the Region's priorities were established as: continuing medical education, improved rehabilitative care, and better and more prompt diagnostic methods. A pre-operational site visit was conducted in April 1969. At that time it was noted that although the core staff was basically an adminis- trative organization lacking professional and expert technical backup, this weakness was counteracted by an active and devoted Regional Advisory Group which was anxious for progress. The key strength of the program was seen to lie in the active support of the private medical sector. Good cooperative relationships and organizational liaison appeared to have been developed within the geographic area, but it was though that the relationship between the Program and the © Medical School could be further developed to better complement each organization. Finally the site visitors agreed that the data collection emphasis had been on the generation of data in general, with little Northwestern Ohio . ; Regional Medical Program -4~ . RM 00063 5/71 attention given to its program significance or effective use. A second site visit to this Region was conducted in May 1970. The need for this visit was born of Committee/Council's review of a request for a core increase. The site team was impressed with the number of interested groups which had been mobilized to show their support for the RMP and the many apparent good relationships which had. been developed. Relationships between the Medical College and the RMP seemed satisfactory as well. There was disappointment over the lack of program outreach, most of the programs being concentrated in the Toledo area. The primary and over-riding concern, however, was with the unsatisfactory core staff and its functions. An elaboration of these concerns appears in the Core section of this summary, pp 7-8 . In view of the dismal discoveries about core staff, a Management Assessment visit for this Region was recommended, along with only one additional year's support for core, without the requested increase. The subsequent Management Assessment visit found most unsatisfactory core management, and the report was sent to the President of the applicant organization, the Medical College of Ohio at Toledo, for action. The present application discusses changes that have been made. See Core section of this summary. Regional Goals: Five program priorities for the coming year are listed in the application: 1. Updating the skills and attitudes of existing practitioners of all health professions. 2. Cooperation in the development of adequate facilities for preventive and ambulatory careof all age groups. 3. Development of Inter-regional Coordination among Ohio and adjacent RMPs. 4. Facilitation of Continuing Educational Opportunities. 5. Cooperation in the upgrading of Manpower Resources. The chart on page 5 of this summary shows the relationship of ongoing and proposed projects to the above five program priorities. RAG and Committee Structure: The RAG is composed of 50 members and meets quarterly. Its Executive Committee meets monthly with core staff to facilitate the administrative super- vision of the program. All actions of the Executive Committee are subject to RAG review and any fundamental questions of policy are referred to the full group. The NWORMP is divided into four subregions and each is represented on the RAG. and Executive Committee. In addition, there is a Continuing Education Planning Committee for Non-Physician Health Personnel in each of the subregions. Four categorical reference panels act as advisory groups to the RAG. There are five other groups in the areas of lower respiratory tract neoplasms, continuing education, NORTHWESTERN OHIO REGIONAL MEDICAL PROGRAM ANNIVERSARY REQUEST Categorized by Regional Program Priorities 03 Year Updating Skills & Devel. Facilities Inter-regional Upgrading Attitudes of for Preventive & Coordination Continuing Menpower Total Core Practitioners Ambulatory Care Education Resources Request Continuation Stroke Rehab. Trng. Uterine Cancer Ottawa Valley Ottawa Valley . Control CE Council (see inter-reg. Coord.) _Dial Access . - Committed $ 1/ Intensive Nurse CCU Trng. Smoking & Health $484,817 $331,454 $97,188 $20,525 $35,650 Renewal Core New $ $417,850 . $417,850 Approved/Unfunded CE for Physicians Patient Problems - Nurse & AH CE New $ $125,000 - . $125,000 New Core . Supplement Cancer Detection Healch Careers Community Hosp. Low Income Pop. in Ohio -HCIO Libraries (see Core suppl.) New $ Toxicology Lab. $196 ,852 $25,000 $130,788 $41, 064 Developmental Home Trng. in Component . Hemodialysis New $ $100,000 $100, 000 Total $442,850 $331,454 $227,976 $120,525 $201,714 61,324,519 Af The Region requested in excess of it reduced to around $400,000 due to RMPS fiscal constraints. s committed level of $445,825 which recently has been -6- Northwestern Ohio Regional Medical Programs -~6- RM 00063 5/71 multiphasic health screening,information/systems, dental diseases ~ and RMP/CHP collaboration. . Review Process: Project ideas,which are solicited periodically from the Region's health personnel, are first submitted to the core staff and then to the appropriate reference panel for approval and assistance in development. CHP also reviews for approval or disapproval of continuing the development of the proposal. A core staff member writes the proposal in accordance with RMP guidelines and with the assistance of other appropriate core personnel and CHP groups. Endorsement of the proposal is obtained from the people, institutions, and reference panels affected by it and is then submitted to the Executive Committee of the RAG. Upon Executive Committee approval, the proposal is submitted to the total RAG. CONTINUATION WITH COMMITTED MONIES OF SIX ONGOING ACTIVITIES The activities for which continuation support is requested are: Stroke Rehabilitation Training Uterine Cancer Control Itensive Nurse CCU Training Smoking and Health Dial Access " Ottawa Valley Continuing Education Council (Co-funded with Ohio State RMP) A breakout of these activities categorized by program priorities is on page 5 of this summary. Although the committed monies for these six activities were $445,825, the amount requested in the anniversary application is $484,817. In addition, RMPS financial stringencies have reduced the commitment to around $400,000. SO During staff review of this application there were a number of unresolved problems which are noted as items of concern on pp. 1-2 of this summary. Because staff continues to have serious concerns regarding the management and viability of the Northwest Ohio RMP, it recommended that*: 1. The 02 operational year be extended for a six-month period, through December 31, 1971, at the Region's current rate of expenditures, not to exceed an annualized level of $702,924 (approximately $351,462 for six months) for the support of core and the six currently funded operational projects. 2. The six-month extension period be used to conduct a site ’ visit which should be more in the nature of an assistance than a traditional visit, to serve the following purposes: *Not yet (3/19/71) approved by Director. Northwestern Ohio Regional Medical Program ~i- RM 00063 5/71 a. Determine the actual progress which has been made with reference to the recommendations of the May 1970 site visitors and the subsequent Management Assesment Team. b. Evaluate the capability of the Region, with its present staff, to conduct its program, RENEWAL OF CORE SUPPORT AND HEALTH CAREERS CORE SUPPLEMENT Requested Core: During the May 1970 site visit, the following Third Year observations about the core staff were made: $417,850 Renewal 25,000 Supplemental 1. ‘The program planner-evaluator and epidemiologist $442,850 Total Core who had been appointed at the suggestion of the April 1969 site visitors had little experience or background to perform their required duties. 2. The three physicians who were Chairmen of the categorical reference panels (supported 50% of time from core budget) were devoting far less than 50% of their time to the function of planning and project development, 3. Core staff functions were not well defined and bore little relation to position titles. 4. The Program Coordinator, whom the site visitors believed to be a sincere, devoted and dedicated physician, was unsuccessful in providing the required leadership to the Region. The subsequent Management Assessment report confirmed the site team's gloomy findings, elaborated upon the causes of the core management embroglio, and sent recommendations for their solution to the grantee organization for action. The present application (pp. 67-70) explains what steps have been taken to correct some of the deficiencies noted in the Management Assessment Report. The areas addressed are: low staff morale, inadequate core staff involvement in RMP activities, poor indoctrination of new employees, shortcomings in core input into financial management, lack of regular staff meetings, organizational lines of authority, management documents, interference with project activity by core staff, control of time cards, purchasing authority, site of RAG meetings, distribution of reference panel meeting minutes, and reference panel membership. In an effort to tighten up on core administration, the staff has been reorganized. Primary changes include the addition of an Associate Coordinator for Administration, the creation of a full-time position for Deputy Program Coordinators, and the freeing of the Coordinator from administrative detail to enable him to devote more time to medical aspects of the program. The application states that overall Til. Northwestern Ohio Regional Medical Program -3- RM 00063 5/71 program direction by the Coordinator and Deputy Program Coordinator now ptoceeds in close liaison with the Executive Board of the RAG. In addition to renewal funds for continuation of core activities $25,000 is requested as NWORMP's contribution to the program Nealth Careers in Ohio, to which three Ohio RMPs are contributing. It is being conducted under the auspices of the Ohio State RMP and igs centered in Columbus. Applications in the current review cycle _ request funding for the next year for this program as follows: Ohio State RMP $145,000 Northeast Ohio RMP 50,000 Northwest Ohio RMP 25,000 $220,000 Ohio Valley RMP contributed $5,000 to this activity last year, but has since withdrawn its support. The NWORMP will re-evaluate the objectives and activities of this Health Careers Program before determining the type and quantity of support beyond 1971. ACTIVATION OF TWO PREVIOUSLY APPROVED BUT UNFUNDED ACTIVITIES Project #14 - Continuing Education for Physicians. This Requested project is not described in the anniversary ' First Year application. June/July 1970 Committee/Council recommended $75,000 approval of $75,000 for a one-year feasibility study (not to be included as part of core) which combined the programmatic aspects of two separate but similar continuing education proposals which were presented for their review. Essentially, the two proposals , were for the implementation of continuing education programs based on needs identified by physicians throughout the Region, the identification of certain hospitals as learning centers, and the presentation of regional conferences and clinical programs. Approval was predicated onthe belief that the Region was beginning to make some sincere efforts in continuing education and that more planning time was needed to allow a coordination of its efforts. The region sees this activity as contributing toward its continuing education program priority. Project #17 - Patient Problem-Oriented Education Program Requested For Professional Nurses and Allied Health First Year Personnel. This project is not described in the anniversary $50,000 application. June/July 1970 Committee and Council recommended two- year approval of this project as a feasibility study not to be in- cluded as part of core. It was thought that the reduced amount of $50,000 per year would be sufficient funding. The principal objective Iv. Northwestern Ohio Regional Medical Program ~9- RM00063 5/71 of this proposal is to help bring about a regional distribution of appropriate knowledge to all non-physician health personnel regarding current trends and changes in the concepts of care of patients with heart disease, cancer, stroke, or related diseases. Approval was recommended because it was though that the planned subregional committees and the inter-professional aspects of this activity might develop into this Region's first example of a truly regionalized program. The Region sees this activity as contributing toward its continuing education program priority. INITIATION OF THREE NEW ACTIVITIES Project #20 - Detection of Cervical Cancer in a Low-Income Requested Population with Adjunctive Teaching of First Year Breast Self-Examination. This proposal is for the continuation $31,070 and expansion of a cervical cancer detection program started in 1967 under a USPHS grant at the Maumee Valley Hospital, now the Teaching Hospital of the Medical College of Ohio at Toledo. The service presently is available not only at Maumee Hospital, but at migrant worker clinics in four counties, the Planned Parenthood League of Toledo, and the Toledo Health Department. The project will be expanded programmatically with the addition of education in breast self-examination, and geographically with the extension of services to Toledo State Hospital and, hopefully, the outlying county health departments of Northwest Ohio. Second Year: $28,584 : Third Year: $31,070 Project #21 - Northwestern Ohio Regional Toxicology Laboratory. Requested The Toxicology Laboratory of the Medical College First Year of Ohio at Toledo is proposing to function as a 24-hour-a-day $99,718 regional toxicology laboratory to provide analytic toxicology service to other medical institutions in the region,as follows: 1. Perform assays on specimens submitted by any hospital in the Region for drug/chemical poisoning 24 hours daily. 2. Assist coroner's office in determining the nature and cause of death in suspected drug abuse cases. 3. Provide service for monitoring durgs in the urine for various drug addict rehabilitation programs. 4, Provide analysis and indentification of confiscated illicit drugs for area law enforcement agencies. Second Year: $90,023 Third Year: $80,665 Northwestern Ohio Regional Medical Program -10- RM 00063 5/71 Project #22 - Proposal for Improving Library Services. . Requested ; In this project,’ under the auspices of First Year 4 the Medical College of Ohio at Toledo, a consultant 7 $41,064 : will survey each hospital in the Northwest Ohio Region to 1) determine the needs and potentials of the hospital libraries, 2) suggest ways to enlarge or establish a collection, extend library services, and train personnel, and 3) obtain a commitment from each hospital to support and maintain a library.: People will be recruited and trained or retrained to serve as hospital librarians where there is a need. Several methods will be used | in the training program, including on-the-job training, work-training in another library, and one-day seminars. Once the program . is established, a librarian will travel, instruct, evaluate, and maintain the training program. Second Year: $30,974 Third Year: $30,117 . DEVELOPMENTAL COMPONENT Requested First Year The entire amount of the requested developmental component $100,000 would be used to support a training program for home dialysis at the Hospital of the Medical College of Ohio at Toledo. a This program is described by the Region as a first step in the a development of a tri-regional renal disease program on pp. 36-43 i of the application. GRB/RMPS 3/22/71 (Anniversary Review) . Real ON Northwestern 0 wee UNCLE RM 66063 5/71 — * Per Joseph Jewell ‘Developmental** 100, 060 18,460 118,460 _ “CORE. 417,850 * __... 417,850 217,282 | 635,132 ‘Gore Supplement —_ _ 25,000* «25,000 | --- 25,900 oe Stroke Rehab. Training 101,425 __. ee : 101,425 36,881 138,306 #2 Uterine Cancer Control 97,188: os 97,188 21,741 118,929 Ba intensive Care ~ : moe! { Nurse Training 187,379” : _ i 187,379 | 71,887 259,265 #6 Smoking & Health 35,650 35,650 ° 10,485 46,135 on —— — — “#7 Dial Access 42,650 ; i 42,659 6,832 : 49,482 E ‘#15 Continuing Medical Ed. 20,525 8 20,525 5,343: 25,868 _ -#14 CE for Physicians $75,000 | 75,000 : 26,000 101,000 _ '#20 Cancer Detection in : _.__Low-Income Population 31,070 31,070 "14,690 45,760 = #21 Toxicology Laboratory a wee ee 99,718 99,718 | 29,909 129,627 #22 Comm, Hospital Librartes: coe eee 41,064 41,064 10,433 50,497 #17 Patient Problems-Nurse - ____ Continuing Education pene gee ee weve we D9 000 50,000 11,164 61,164 ; VOTAL $484,817. $417,850 = $125,000. 296,852 1,324,519 481,107 1,805,626 se oe CYCLE RM 00063 5/71. BREAXOUT OF REQUEST 04 PERICD ' ‘IDENTIFICATION OF i CONTINUING i ‘PREVIOUSLY ' NEW COMPONENT * :ACTIVITIES RENEWAL ‘APPR/UNFUN. ACTIVITIES i DIRECT ‘INDIRECT TOTAL : : ’ : , : i i . i ' t | Developmental i 1 | i | ; CORE : -_ : i Core Supplement i i ‘ \ ’ . : { ; 5 : ; - i ts | #1 | * | 7 ; | #2 : be Si iS A a | #6 :° SD i } : + # | | Ye ’ : i ' ; ; : . . : . t ? ‘ - '#15 * : 21,250 | : : : 21,250 =: 6.375 ©. 27,625 : ? 4 : ! | #14 | 2 #20 ; 28,584 {| 28,584 |! 13,397. 41,981 £21 4 90,023 i 90,023 | . 31,679 121,702 1 : . : j . i ' ' : #22 So 7 - 30,974} 30,974 | 10,958 41,932 “ph Jewell and Mr. Keller (N.W.O. RNP) 2/18/71 : j ; : . 3 TOTAL «=; 21,250 | (| 149,581 «:170,831 | 62,409" | 233,240 me Requested for 2 years only per conversation #0)" | Pm © 7 @ :velopmental 100,000 216,469 ire Supplement Eas Sarr accra wena _ ~~ —~-- we ene ee EON 25 198,305 ween ee ee eee man nc I BB 11S 929 wee ieee ee on _ en (187,379 259, 268 ioc - . _~ _ 85650 46,135 — ce 42,650 «45,482 : —_ - an nn a ES TIS 53,492 31,070. 14,690 45,760 90,724 133, Je i ee 8 070 i 80,665. 80,665 33,574 114,239 270,406 365,568 | oe on : 307 30,127 11,397. 41,514 102,155 134,543 ---3.9,000_ 61,164 ~ A a a 2 et A Me eo aes cane Rene i ee wane og ene 141,852 141,852 59,661 = 201,513. 1,637,202 2,240,379 fi e , oe - (A Privileged Communication) - - © SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE 4 : NORTHWESTERN OHIO REGIONAL MEDICAL, PROGRAM . RM 00063 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: That additional monies be provided for one additional year of operation. : “ : | . Continuation Commitment Year Request Recommendation 03 $484,817 $391,764 04 21,250 -0- 05 -0- : -0- Total $506,067 , $391,764 Renewal of Core Year Request | Recommendation © 03 $417,850 $295,540 04 =0- -0- 05 ~O- -0- wo Total _ ‘$417 ,850 295 ,540 Supplemental Funding Year Request Recommendation 03 $421,852 -0- 04 149,581 ~0- 05 141,852 -0- Total $713,285 -0- Total Anniversary Request Year Request _ Recommendation 03 $1,324,519 $687,304 04 170,831 ~QO~ “05 141,852 -0- Total $1,615,952 $687,304 Maximum te e Northwestern Ohio .. . -2- RM 00063 5/71 . Critique: The Committee reviewers recalled the reports of the May 1970 site visitors and the subsequent management assessment team. which raised multiple serious questions about the organization and management of the NWORMP, The present application indicates that the Region has taken steps to correct the identified deficiencies, but the. Committee, along with recent staff reviewers, was uncertain of the success of the changes which have been made. The following specific problems, were described as illustrations of areas of concern: 1. Lack of information as to the capabilities of the new Deputy Program Coordinator and the New Associate Coordinator. for Administration and their! respective roles - particularly their relationships to the Coordinator. For instance, under the new organization it appears that everything within core staff flows through the Deputy Coordinator to the Coordinator. The written rationale behind the reorganization was the freeing up of time for the Coordinator to pursue further relationships with the physicians in the Region. The Committee reviewers, however, believe the entire organization and functional structure should be scrutinized, especially with regard to the desirability of using internal reorganization as a method of circumventing a Coordinator's administrative shortcomings. 2. The attendance of all regular staff meetings of the RAG Chairman and the President of the Medical College raises questions as to their precise roles in the administrative structure of the organization, as opposed to the policy-making structure. 3. Concern was expressed about the limited consumer input on both the RAG and its Exeuctive Committee. Further, the relationship of . the Executive Committee to both the RAG and the Core staff was questioned--- it was unelear to the reviewers which group had authority for which decisions. _4&, One of. the concerns of early site visitors was the relative role, or lack of role, of the Medical College. Since all three new proposals and developmental component activities are based at the Medical College, reviewers wondered whether perhaps the pendulum has swung in a new direction and whether perhaps the Medical College is using RMP to mount basic programs for the school itself. 5. The fragmentation of the State among the Northeast Ohio, North- west Ohio, and Ohio State Regional Medical Programs, It was thought that before any decision could be made regarding the ultimate future of this Region, a site visit team would have to deter- mine the actual progress which has been made in the administrative and organizational realignment and the capability of the Region, with its present staff, to conduct its program. As with the Northeast Ohio RMP, the reviewers essentially were questioning whether this is indeed a viable region, And in view of this underlying question, the staff concerns listed on pages one and two of the yellow summary and the apparent fundamental administrative deficits, the consensus was that the NWORMP should be Northwestern Ohio -3- . + RM 00063 5/71 supported for one additional year at its current rate of expenditures,’ not to exceed a level of $687,304, with similar holding actions being taken for the Northeast Ohio and the Ohio State RMPs. Each of the three Regions should receive a site visit to concentrate on that program's problems, strengths, and weaknesses. After these three informat ion- gathering visits, a second-stage consultative visit should.include the RAG chairmen, Coordinators, sponsoring institution representatives, ‘and other officials of each program to discuss amalgamation of the programs. The one year continuation of the three separate RMPs, then, is viewed by the Review Committee only as an interim step toward the unification of Ohio. , CONTINUATION WITH COMMITTED FUNDS OF SIX ONGOING ACTIVITIES Continuation funds were requested for the following activities: Stroke Rehabilitation Training Uterine Cancer.Control Intensive Nurse CCU Training Smoking and Health Dial Access Ottawa Valley CE Council The Review Committee agreed that continuation funds should be provided for one additional year, calculated on the current rate of expenditures. RENEWAL. OF CORE SUPPORT The Committee consensus was that core should be renewed for one additional year, the actual amount to be calculated on the current rate of expenditures. SUPPLEMENTAL FUNDING Supplemental funding was requested for the following: A. Supplemental core support for NWORMP's contribution to the program Health Careers in Ohio. In view of the staff opinion that expansion of this program exceeds the bounds of permissible RMPS support, the Review Conimittee recommended disapproval of supplemental monies for its expansion. B. Activation of two previously approved but unfunded activities: Continuing Education for Physicians and Patient Problem-Oriented Education Program for Professional Nurses and Allied Health Personnel. Although no additional funds were recommended for the initiation of these activities, the Region is not prohibited from exercising its rebudgeting authority for their conduct. C,. Initiation of three new activities: Detection of Cervical Cancer with Adjunctive Teaching of Breast Self-Examination, Northwestern Chio Regional Toxicology Laboratory, and Proposal for Improving Library Services. - \ « Northwestern Ohio . -4-. . _* , RM 00063 5/71 3 ; . : . Consider?ng the numerous and serious problems which the NWORMP is ©} experiencing, the Review Committee could recommend no additonal funds for the initiation of these new projects. The Region is not prohibited, however, from beginning the activities with rebudgeting funds, if it chooses. D. A developmental component. The designation of the entire amount of the developmental component for a renal dialysis effort raised questions for the Committee as to the Region's understanding of the potential uses of such monies and the Regional decision-making process. The recommendation was for disapproval of developmental funding. RMPS /GRB/4/21/71 1 na ae REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) OHIO STATE REGIONAL MEDICAL PROGRAM RM 00022 5/71 1480 West Lane Avenue April 1971. Review Committee Columbus, Ohio 43221 Program Coordinator: William G. Pace, III, M.D. This Region presently is funded for its 02 operational year at a direct cost figure of $973,793, which includes carryover of $60,589. During this period the Region received indirect costs of $182,037 which represents an overall indirect cost rate of approximately 19%. The current budget period ends June 30, 1971. This application requests support for: I. A developmental Component Il. Continuation with committed support of core and two ongoing activities. Ill. The renewel of three activities. Iv. The activation of three Council-approved but unfunded activities, and expansion of core. V. The implementation of nine new activities. VI. Termination of two activities. The Region requests $1,832,892 direct costs for its third year of operation, $1,871,877 for the fourth, and $1,728,866 for the fifth year. A breakout chart identifying the components for each of the 3 years is included as pages 15 through 17 of this summary. No site visit is planned to the Ohio State RMP. However, staff review of the continuation request identified certain areas of concern in which the Committee and Council may be interested. These are listed briefly below and are discussed in more detail on page 8 of this summary. 1. The dearth of minority group representation on core, RAG, and the entire regional committee structure, as well as the Region's fulfilling the RAG requirement for members of the public with individuals not parti- cularly representative of the general public (e.g. University Vice President). 2) The possibility that the RAG and core staff are contributing to the institutionalization of the RMP and thereby losing flexibility in dealing with emerging problems, and the affect on program direction of the grantee institution, Ohio State University. 3) The lack of allied health competencies on core staff 4) The role and effectiveness of the Local Planning Committees. 5) The extent to which the activities of this region affect the delivery and organization of health services. 6) The extent and types of cooperative relationships which have been developed. Ohio State Regional Medical Program -2- RM 00022 5/71 7) Inter-regional cooperation among the four RMPs in Ohio FUNDING HISTORY . Planning Stage Grant Year Period Funded (direct costs) Ol 4/67-6/68 (15 months) | $140,271 02 ~—« 7/68-6/69 920,962 7 Operational Program Funded Future Grant Year Period | (direct costs) Commitment 01 5/69-6/70 (14 months) $1,226,971 l/ -- 02 . 7/70-6/71. 973,793 l/ -- Q3 7/71-6/72 -- $642,667 2/ 04 7/72-6/73 . -- 642,667 2/ 1/ ine luded carryover 2/ reduced from previous commitment of $714,075 because of RMPS fiscal constraints GEOGRAPHY AND DEMOGRAPHY The boundaries of the Ohio State Regional Medical Program have remained constant since the Region's planning stage and include 61 counties in central and southern Ohio. Columbus is the geographic and cultural center of this area. Surrounding regions in Ohio are Northeastern Ohio RMP (Cleveland), Northwestern Ohio RMP (Toledo) and Ohio Valley RMP (Cincinnati and parts of Kentucky). The — Region contains the Ohio State University Medical School at Columbus; 14 nursing schools; one physical therapy, two cytotechnology, four medical technology and eight radiologic technology facilities. The Region's 127 short-term non-federal hospitals contain approximately 17,000 beds. There is, in addition, a diagnostic, service and teaching cancer clinic -in Columbus. HISTORY:. After two revisions of its original planning grant application to provide clarification and evidence of regional participation, program leadership, RAG status and other considerations, the Ohio State Regional Medical Program received a small planning award in April 1967. The interim Program Coordinator (Dr. Richard Meiling) was replaced by Dr. Neil C. Andrews in November of that year. The second year planning grant, of a considerably larger magnitude, included funds for core expansion, and four feasibility studies (one being earmarked monies for a mobile coronary care unit study). A pre-operational site visit to the Ohio State RMP was conducted in December 1968. Although there were unanswerable questions about the program, since it was still in the developing stage, the site visitors (and subsequent Committee and Council reviewers) agreed that sufficlent Ohio State Regional Medical Program -3- RM 00022 5/71 progress had been made to justify an operational award. Peripheral and local involvement of health personnel appeared to be proceeding well. The Local Planning Committee structure was considered particularly laudatory. The program was not as university dominated as had been expected and the quality of the core staff was thought to be good. The major concern about the Region was that the Regional Advisory Group had not yet become active. It had not developed an overall program plan or regional priorities and it had not involved the area's significant black population. An O1 operational award was granted for the support of core and 7 projects. Since that time, there has been no program site visit to this Region, and Committee, Council and staff have kept track of the Ohio State RMP primarily through review of its project applications. Some programmatic considerations which have arisen in the various reviews are: 1. Questions of the extent and quality of cooperation among the four Ohio RMPs. 2. The actual merits of the area continuing education councils which are proposed for initiation throughout the Region, (in the present application, continuation support is requested for one, renewal support for another, and new money for still a third which has been approved but remains unfunded--a fourth CE council proposal has been disapproved by Committee and Council on the grounds that evidence of the effectiveness of the approach was needed.) 3. Although during 1970 the RAG seemed to have become more active and had formulated at least general plans for the Region, it remains weak in consumer and minority group representation. 4, In the fall of 1970, Committee and Council reviewers remarked on the fact that of the last 13 project proposals submitted by the Region, only three had emerged from national review with recommendations of approval, and two of these were renewals. It was thought that this record did not reflect well on the local review process. , The current coordinator, Dr. William Pace, has been on board since February 1970. The Ohio State Regional Medical Program now is completing its 02 operational year. The current funding situation is summarized on the next page. Ohio State Regional Medical Program he RM 00022 5/71 con SUMMARY OF OPERATIONAL PROJECTS CURRENTLY " Neggpten® BEING SUPPORTED BY OHIO STATE RMP . Project Number and Title Future Years of Funded (d.c.) Commit. Support 7/1/70-6/30/71 Core | 7 2 $533,245 #2 - Coronary Care Unit Education 1 55,572 _ #3 - Stroke Rehabilitation Training for Health Professionals 0 33,952 #4 - Careers in the Health Service Program 0 25,400 #6 - Mobile Coronary Care Unit 0 107,623: #8R- Computer-Assisted Instruction 2 160,000 ’ #11- Council for Continuing Education: Springfield 0 , 37,171 #22- Council for Continuing Education: Ottawa a ee 20,830 ' Total $973,793 REGIONAL ADVISORY GROUP In November of 1970 the Regional Advisory Committee of the OS/RMP adopted new by-laws and procedures which define thetfanctions of the RAG: 1. identification of health care needs and problems 2. establishment of priorities for their solution '3. periodic revision of program direction as needs and priorities change Also, at the time, a nominating committee was established to diversify RAG representation. There currently are 34 RAG members, of which one is black, but the by-laws provide for 45 members and a slate of candiates apparently now is being prepared, PROGRAM DEVELOPMENT AND REVIEW PROCESS During the pre-planning stages of project development, core staff works closely with the sponsors of each particular proposal in defining the need, determining the relationship to OS /RMP program goals, and available sources of support, and finally in the actual development of the project proposal. Each final application receives review and comment by the appropriate technical review committee orvstask force, as well as CHPXb) agencies, before being sent on to the Review Committee. (two or three Ohio State Regional Medical Program -5- RM 00022 5/71 RAG members assigned by the Program Coordinator plus the technical. committee). There currently are five standing task forces: Heart, Cancer, Stroke, Kidney, and Hospital Services. The Review Committee consideration of each proposal is the first point in the review process at which a decision regarding further progress can be made. All prior staff and task force review is advisory only, but the Review Committee decides whether to forward a proposal to the RAG (although there is an appeals procedure for the sponsor). The RAG is the final decision-making body. REGIONAL NEEDS AND PRIORITIES In November 1970, the RAG reconsidered its previously adopted (1968) general goals and recast them in a more specific framework of needs. and priorities. The four identified categories of need and priorities within them are stated below: A. Education 1. That knowledge regarding the treatment of heart, cancer, stroke, kidney, and related diseases should be maximally known by the health professional within the region. 2. That knowledge regarding appropriate personal care and seeking of treatment for symptoms of heart, cancer, stroke, kidney and related diseases should be maximally known by the public within the region. B. Health Care Resources - Manpower 1. That adequate manpower in all health care categories be recruited. 2, That health care manpower be distributed to maximize excellent health within the region. 3. That health manpower categories be developed which best meet the needs of the region. C. Categorical Disease Programs 1.. That as far as possible there should be the elimination of heart, cancer, stroke, kidney and related diseases. 2. That as far as possible those with the sequellae of heart disease, cancer, stroke, kidney and related disease be rehabilitated to the maximum physical, psychological, medical, and social level of functioning. D. Resource Coordination and Assistance 1. That the various regional health care resources coordinate their activities in a manner to maximize their effectiveness. 2. That assistance be available to health care resources to enable them to develop eventually self-supporting programs that accomplish other objectives of the OS/RMP. _ if. Ohio State Regional Medical Program -6- RM 00022 5/71 These are elaborated upon on pp. 35-37 and 46-88 of the application. A chart showing the 03 year request as it relates to the stated regional needs is included as page 8 of this summary. CORE The core staff was reorganized in October 1970, at which time a Division of Community Relations was created and given responsibility for subregionalization. The primary vehicle for subregionalization is the eleven Local Planning Committees (recently reduced from 14 to more closely approximate CHP B agency boundaries) which vary in size from five to 32 members each. The responsibilities of the Local Planning Committees are stated to be the assessment of resources, the identification of problems, the establishment of goals, and the recommendation of action to the RAG. The new Division of Community Relations will work to strengthen these local groups, engage in project monitoring activities, and carry out public relations and information functions. The reorganization also created a Planning and Evaluation Unit which will serve to involve core staff more in the evaluation activities of individual projects. This Unit also will seek to determine the effectiveness of the Region's resource allocations and will initiate a data and information system. The current core staff roster includes 17 professional positions (all but 3 full-time) and one vacancy. For a description of the areas in which funds are requested for expansion of core, see pagel0 of this summary. COMPONENTS OF PRESENT APPLICATION DEVELOPMENTAL COMPONENT The application states that Requested developmental funds will be used First Year to conduct special studies, short-term pilot activities, or $97,379 special research projects’ consistent with the Region's goals. Each proposal for use of developmental monies will be required to complete the regular regional review procedures. The first year request is slightly in excess of that allowable, and the subsequent two Years are based on the total requests for those years contained in this application. Second Year: * $183,289 Third Year: $187,187 CONTINUATION REQUES$ The Region is requesting the continuation at the committed level of core activities and two ongoing projects: #8R - Computer-Assisted Instruction, and #22 - Ottawa Valley Continuing Education Council (jointly funded with NW Ohio RMP). The application requests a commitment of $714,075, although the Region recently has been informed that the amount will be reduced to $642,667 because of RMPS fiscal constraints. Staff reviewers have recommended that the new reduced amount be awarded, but at the same time identified areas of concern in which the Committee and Council might be interested. 1.. Although the 1968 site team had suggested to the Region that the area's. black population be involved, two years later the number of minority Ohio State Regional Medical Program -7- RM 00022 5/71 representatives on core staff, the RAG, and the entire regional committee structure is insignificant. Further, the RAG representatives who are designated as members of the public appear to have been included by virtue of their professional and public images, and not because they are representa- tive of the general consumer public. 2, Staff wondered whether this RMP might not be becoming institutionalized through the apparent unwillingness of core staff and the RAG to adapt to new situations. Staff also observed that the Region might show a greater response to community needs if the RMP were incorporated and separated from the present grantee institution, Ohio State University. 3. The lack of allied health personnel on the core staff was noted. ‘4. I£ was difficult to determine the role of the Local Planning Committees. How do they relate to other community planning groups? What activities have bubbled up from these local committees? Are they included in the formal regional review process? 5. What impact does this Region hope to have on the organization and delivery of health services, and does its activities reflect the right approach? There are no indications, for instance, that the Region has investigated the health needs of the Model Cities areas or what it might do in the development of viable health programs in such areas. 6. It was impossible for staff to determine the extent of cooperative relationships which had been developed within the Region. Although numerous Forms 9 (Core Cooperative Relationships with Other Organizations) were submitted as pp. 107-139 of the application, for the most part they reflect only the organizational affiliations of RAG members. Staff could not teil whether the Region misunderstood the purpose of the forms or whether there were few joint undertakings to report. 7. The extent of joint participation and cooperation among the several Ohio Regional Medical Programs is open to question; Despite the above questions, the consensus was that the Region should be supported at its committed level. The recent core reorganization provides for a Planning and Evaluation Unit as well as a Community Relations Division. Although it is still too early to measure the quality of evaluation activities, the Region's growing awareness of the necessity for evaluation is reflected in this reorganization. The Community Relations Division should do much toward helping the Local Planning Committees hone in on community problems and devise solutions, and there are indications of a developing relationship with CHP. Further, there is evidence of core's emphasis on functioning as a catalytic agent. The RAG is still in transition, but appears to be moving into a firmer decision-making role with the identification of RAG functions and a new interest in formulating a workable regional plan. Hopefully, there will be a concomitant move away from OSU dominance. PROGRAM AREA _ OSGOISE COMPONENTS Continuation (committed $) COMMUNITY BESOURCE . ADMLNISTRATION CONTINUING EDUCATION HEALTH MANPOWER rATEGORICAL DISEASES q SUPPORT REQUESTED 03 YEAR Core Computer-Assited Instruc- Health Careers in tion . : Ohio Ottawa Valley CE Council \ Committed ($533,550) ($180,525 (funded through Core} $714,075 L/ Renewal Tri-County CE Council cCCcU Training Stroke Rehab. Trng. New (new $) ($40,049) ($82, 019.) $122,068 APPROVED/UNFUNDED Core Expansion Greater Portsmouth Volunteér Health Phonocardioscan . + COMPONENTS CE Council Services “Screening ' rs o a New (new $) ($450,870) ($10,976) ($145,900) ($62,400) $540,146 PROPCSED COMPONENTS POMR - Marion Cancer Control Centralized Hospital Medical Social Services pediatric Nephrology Preadmission Cadaveric Transplant Prug Info. & éMalysis, New Hypertension Detection $359,224 oy Home Dialysis (new $} ($42,410) . ($278 ,848) ($37 , 966) Subtotal $984,420 $273,960 $15,900 $423,267 $37,966 $1,735,513 Developmental Component 97,379 2/ Total ' $1,832,892 1) Recently reduced to $642,667 2/ Developmental comroneat request ts $6,000 in exces s of the allowable 10% of 02 year level Iv. Ohio State Regional Medical Program -9- RM 00022 5/71 RENEWAL REQUEST PROGRAM AREA: CONTINUING EDUCATION Project #11R - Tri-County Continuing Education Council . 3rd Year $40,049 Support is requested for the third, fourth and fifth years of this activity, after which time it should be totally self- supporting. The goal of the project is the provision of continuing education programs to local health professionals of Champaign, Clark, and Logan counties to enable them to deliver the best possible care. A 32-member council functions, for the most part, with and through other organizations and agencies, serving as coordinator, catalyst, liaison, clearinghouse, and resource center, as well as an occasional source of money to help launch continuing education activities. Local funds on a shared-cost basis are required for most activities. Local acceptance of the council has openedthe possibility of its expanding to include two additional counties. It is hoped that a professional library source can be developed. 4th year: $39,774 Sth year: $39,688 PROGRAM AREA: CATEGORICAL DISEASES Project #2R - Coronary Care Unit Training 3rd Year $48,050 The first two years of this activity concefitrated — on the actual training of nurses in CCU techniques, but the final two years, for which renewal support is. being requested, will be concerned primarily with assisting hospitals in developéag self-supported CCU training programs. Gore area classes will be continued, however, on a selective basis and co-sponsorship for the courses sought from local organizations, but these classes will decrease as hospital in«service training increases. 4th year $48,800 Sth year -=0-" Project #3R - Stroke Rehabilitation Training 3rd year $33,969 A third and final year of funding is requested for this community-based program of education in stroke management. During the coming year, emphasis will be placed on evaluation, distribution of information about the program and providing consultation to other communities interested in developing similar programs. APPROVED/UNFUNDED ACTIVITIES FOR WHICH NEW MONEY IS REQUESTED Supplemental money is requested for the activation of three activities and #m expansion of core which have received previous Council approval but for which funds have not been included in the grant to the Region. Ohio State Regional Medical Program -10- RM 00022 5/71 Core Expansion June/July 1970 Committee/Council 3rd Year. $450,870 recommended approval for three. years of supplemental funding ($533,265, $598,286 & $666,694) for a general and non-specific expansion of core staff and activities. The additional monies which are requested for core expansion would be distributed as follows: Administration ‘$ 190,000 Manpower - 110,000 Categorical Diseases 63,585 Coordination of community resources 50,000 Inter-regional coordination 37,285 $110,000 is requested to supplement the $35,000 of committed monies for the program Health Careers in Ohio (HCIO)Y. Initiated in March of 1970 and centered in Columbus, this activity represents a cooperative venture among three RMPs in Ohio, and each is contributing funds to the OS/RMP for its support. Ohio Valley RMP contributed $5,000 last year, but has since withdrawn support. The applications in-house request the following for HGIO for the coming year: Ohio State RMP $145,000 N.E. Ohio RMP 50,000 N.W. Ohio RMP 25,000 $ 220,000 The $37,285 for inter-regional coordination probably is for the addition to core of a staff person responsible for facilitating communication and cooperation among the Ohio Regions. ' Beyond thege two items, further specifications as to the use of the core supplement is not included in the application. 4th year: $470,000 5th Year: $485,000 PROGRAM AREA: CONTINUING EDUCATION Project #14 - Greater Portsmouth Area Continuing Education Requested Council - Implementation of this project would First Year bring to a total of three the subregional continuing $10,976 education councils in this Region. The other two are the Ottawa Valley and the Tri-County Councils. The Greater Portsmouth Area Council would create a mechanism for planning, development and implementation of a cohesive program of educational activities for members of the health professions in five rural counties in southern Ohio. The July 1969 Review Committee felt it could not recommend funds for yet another council of this sort in the absence of evaluative and experiential data from those ongoing. August 1969 Council, although recognizing the Committee's concerns, recommedded approval as requested and suggested the Region be advised of the necessity for the careful planning and development ie Ohio State Regional Medical Program ~1ll- RM 00022-5/71 — of such projects as an approach to improving health care delivery in communities away from a medical center. 2nd year: $11,399 3rd year: $11,844 PROGRAM AREA: HEALTH MANPOWER Project #26 - Program to Improve Volunteer Services Requested Using several hospitals as demonstration First Year base institutions (six to ten), this project hopes to , $15,900 develop new and productive ways of using volunteers in community health care and evaluate the emerging role of voluntarism in the health field. November 1970 Committee/Council in reviewing this request believed — the improvement of patient care through the use of volunteers to be of questionable value. Consequently, additional funding for the conduct of this project was not recommended, although the Regionrwas not precluded from initiating it through rebudgeting. 2nd year: $16,852 3rd year: $17,899 PROGRAM AREA: CATEGORICAL DISEASES Project #15 - Central Ohio Phonocardioscan Screening Requested The goal of this project is to provide First Year heart-sound screening for 150,000 children in 47 counties $62,400 and to establish this program as a permanent par& of school health examinations. December 1969 Committee /Council befieved this proposal represented an acceptable, inexpensive, and efficient approach to screening for heart disease in children, and recommended approval in the amount requested. ~ ™ 2nd Year: $63,300 3rd year: 560 Boo NEW ACTIVITIES PROGRAM AREA: CONTINUING EDUCATION Project #31 - Development of POMR System in a Community Requested Hospital - A medical records system will be Firat Year established in the Marion General Hospital to provide a $32,410 more relevant and complete medical data base upon which to implement comprehensive health care for patients. The operating schedule calls for three year-long phases: Phase I for training, development and initial evaluation; Phase II involving interregional computer linkage with the Vermont Medical Center; and Phase III for full-scale operation. Some core funding and staff expertise and Marion General Hospital funding already has been invested, and this project is, in fact, in its initial phase. 2nd. year: $46,321 3rd year: $46,321 Ohio State Regional Medical Program -12- RM 00022 5/71 Project #33 - Training Program for Medical Social Service Raguested “= Personnel in Hospital Settings - Short-term First Year in-service education and training programs will be developed $10,000 for those individuals who have. been assigned medical social service responsibilities in hospitals, extended care facilities, and home health programs. The program will encourage the use by patients and their families of available local and regional health, welfare, oy rehabilitation, education and other resources. It is anticipated that after the program is established, participating hospitals will incorporate medical social services into their overall programs. . 2nd year: $10,480 3rd year: $10,984 PROGRAM AREA: CATEGORICAL DISEASES Project #34 - Cancer Management Evaluation The purpose Requested of this project is to define cancer First Year management problems in the Region and develop and recommend $29,998 programs for their solution to responsible and interested \ individuals in each county. Evaluation of responses to suggested areas for improvement in each=county will be obtained by determining at six-month intervals the new local programs which have been planned or enacted since the suggestions were made. 2nd year: $30,823 3rd year: $31,690. Project #28 - Pediatric Nephrology Center This proposal Requested is for the establishment of a program for First Year end-stage kidney disease for children and adolescents at $67,700 Children's Hospital in Columbus. The Center will provide diagnostic and treatment services to kidney patients, including hemodialysis, transplantation, and pre and post transplantation supervision and care. It also will serve as the source of information for the area and will offer training programs for practicing physicians and pediatricians. All activities of the Center will be integrated with the Center for Adults in the OSU College of Medicine, and OSU will support a pediatric nephrologist to be recruited for this Center. 2nd year: $67,294 3rd year: . $70,384 Project #27 - Cadaveric Transplant Program It is planned Requested to establish a mddel that will demonstrate First Year that an agressive program of organ procurement will $100,750 increase the supply of organs, decrease the patient's costs, and improve the results of cadaveric transplantation. This will be accomplished through three primary thrusts: (1) public education, (2) physician education, including patient suitability for donation, j procurement techniques, and legal responsibilities, and (3) training and utilizing allied health personnel to perform many of the tasks of organ procurement now performed by the transplant surgeon. The project Ohio State Regional Medical Program -13- RM 00022 5/71 will cooperate with the National Organ Procurement Program and obtain continuing support by hospitals assuming part of the costs through third party payments and local lay foundations. 2nd year: $85,394 3rd year: $90,194 Project #30 - Program for Hypertension Detection This Requested three-year feasibility study is for the purpose First Year of detecting hypertension and determining if effective means $28,900 can be devised to bring available methods of blood pressure control to individuals in lower income groups. A public education campaign will be launched, and a screening program aimed particularly at the black population will be carried out. Individuals in whom hypertension is detected will be referred to either their private physicians or to one of several clinics to be set up in the Model cities area-in cooperation with the Columbus Metropolitan Area Community Action Organization. These clinics will be held during evening hours at existing clinic locations of Children's Hospital and will be staffed by project physicians and paramedical personnel trained through resources of OEO. 2nd year: $29,956 3rd year: $31,096 Project #29 - Home Dialysis Program To implement Requested dialysis training, two dialysis coordinators First Year will be employed: one in Dayton and the other in Columbus. $51,500 Both will be trained in extra-corporeal technology and will seek to establish patients on home dialysis at the earliest practical moment. In addition, the coordinators will ensure that initial problems related to home dialysis are resolved. It is hoped that after three years, the salaries of the coordinators could be assumed by third- party payments or local kidney association funds. 2nd year: $53,700 3rd year: $56,010 PROGRAM AREA: COMMUNITY RESOURCE SUPPORT Project #35 - Centralized Hospital Pre-Admission Health Requested Evaluation This project proposes the First Year performance of a total health evaluation as a part of $19,966 preadmission procedures at the five hospitals in the Greater Dayton area. It is expected that the performance of preadmission tests for ambulatory patients in an out-of-hespital setting will shorten the hospital stay and result in reduction of per-patient costs and the freeing of hospital beds for use by other patients. Specifically, the Region estimates that the community could save about $1,5 million in per patient costs annually and about $9 million in new hospital construction. Physicians will be able to obtain standardized, transferable medical profiles on their patients which will improve their management of patients and, through time saved, extend their services to more patients. Only one year's funding is requested. VI. Ohio State Regional Medical Program -14- RM 00022 5/71 8 . ve} Project #32 - Drug Information and Drug Therapy Anaylsis Requested xe and Reporting Center The services of the ‘First Year drug infoymation analysis center of the Ohio State University $18,000 (which has been operating since 1962) will be extended and regiona- lized. It will provide health professionals with current and comprehensive information concerning drugs and drug therapy. Although service’ to physicians will be first priority, dissemination programs will be developed.to expand the Center's use by pharmacists, dentists, nurses and other heaith. prac- titioners. This is a one-year request only. TERMINATING ACTIVITIES f- Two ongoing activities have no further financial commitment from RMPS and apparently are to be terminated. No progress report on these two projects is contained in this application: Project #4 - Careers in the Health Service Program and Project #6 - Mobile Coronary Care Unit. The Region will submit terminal progress reports soon. -¢t- a. —— - REVISED - 3/9/71 REGION OHIO STATE CYCLE RM 00022) 5/71 BREAKOUT. OF RIQUEST___03 PERIOD (Triennium) | coxtasess¢ | EPREVICUSLY | NEW ; ! [ACTIVITIES iRENEWAL VAPPR/UNFUN. IACTIVITIES | DIRECT “INDIRECT | TOTAL i ~ rs ro $ 533,550 i $ 533,550 :$ 61,202 1 $ 594,852 | - —_ | : CORE -_ SUPPLEMENT . '$450,870 459,870: 37,971 | 482,841 | FBR = Computer Assisted bo. i | i : Instruction ' 160,000 ‘4 i 160,000 14,281 | 174,381 a - Council for CE i i ; i i (Ottawa Valley) t 20,525 | wt 20,525 | 1,692: 22127 i Pa = £CU a 7 $48,050 |. i 48,050. 4,242 | 52,293 mea Rerabilitetion Training ; 23,969 3 : . 33.969 i 2,845 3 26.814 ' CHIR = Tri-County Council i : : | i i i for CE : | 40,949 i. ; 40,049 $3,520 | 43,579 i “#14 - Council. for. CE : i i i { (Portsrounth) : 1 $10, 976~ ~ 10,976 | 1,242 12,218! YTS ~ PhoncCan7ioScan ; 62,40 | $2,400: 2,828 By9e8 #26 - Volunteers Serviccs : | » 15,989 : i 15,990 ; 7,461 °: TF.247 “fo7- Kitney Transelant : i i” $700, 750 (~~ J00, 750 - 17,994 118, 244 : "$28 - Ped. Nenhrology Center : : 1 67,700 67,700 ; 8.923 § 78,6230 —t “#99 +. Home Dialysis : . \ 51,500 51,500 | 8,752} 61,252 a “gan - Hynertension Detection PF 48,900 i 28,900 | 4,180 | aa,0sn Fi" = Pevelonment of the ; | : i ; i ee POMR System : : : \ 22.410 | 32,419 12,7722. 35,142 4 "$22 - Drug Information & - | i ; i ___--. Therany : | is.9no it 8, NO 621 22,421 1 $92 . Medi-socia! Service | : Gg i _ Personne! Training s ! - {o.onn 19,000 | 2,909 12.909 “Pal - Cancer Management. _ | : ot : Evaluation 29,908 |) 29,998 | 2657 32.655 "#95 - Hosnital Pre-Admission j i i - 1 .-—-—Heal rh_Eveluation. ' i 49,966 i 99966 | 2 BF 22.822. "DEVELOPMENTAL 197,379 97,279 | Os 9379 1 ; : : i i : : — _ 7 _ - TOTAL «$714,075 $122,068 $540,146 | $456,603 $1,832,892 | $186,454 | $7,019,346 | — be — KEGION__QHIO STATE CYCLE RM_90022 5/71 BREAKOUT OF REQUEST 04 PERIOD T CONTINUING | ;PREVIOUSLY | NEW : 7 * ACTIVITIES sRENE\ *APPR/UNFUN. \ACTIVITIES DIRECT ‘INDIRECT TOTAL, if { CORE % 532,245 | ; \ $533,245 | 2 i of coe = SUPPLEMENT : } TSaTT, OT _| 479,900 fo = ° |. jf 1Ag,ana i : 169,009 ) 8 ni i ! 21.250 ! r 21,250 | i i i $48,200 r 48,899 | i a | i - ] i to L “d i : F99.774 i _ i i 39,774: mt { rm i i 1 rSy7,299 | TT. ag Fo r o : i T 35,8592} T 76.852 6 ot ‘ v= | \ i i “1 § 85,294 + 85,206 : 4 i ‘ 1 { (67,294 i 67,296 ) oo i ea : i [53,7001 53.700 / 9 ‘ a au i : : 1 29,956 : 79.956 | ' dt a | \ 46,221 | 46,227) i - a ' i ! t --- i wee i z T : : ' 1 10,480 | 10,480 i | | ! i \ } 30, 823 ! 30,823: = ' > ff. : : | ! ~-- \ wan ‘ rd i gy : : i ' T 183,28° + 183,289 ) | 3 : | | | FT : : i | i Mt i a i | i ° | { ' i i i ka | > | | | | | on fos : I t ‘ ' " “8 ; oO I 7 a an : | i | : ! | ~ i i ; } { | : i _ : | ! | a ; | coe : ; VP 92,511 | > ree i { ! --- i --- d i i. 19,956 7 id i ‘DEVELOPSENTAL | | 187,187 | 187,187 2m | 1: 467,855 | ro ; i | | | an E fom | : a [i | a ! oy bi - > | Li > | : i | | a I ao | : i | ! nH } : : o | tl | z | | z | ! | : ! | 7 i { ; : it ‘ : | | | ! | f | ‘ i oa i i ry ! ! | ! | | | mons | $586.569 1 $39,688 | $578,743 $523, 866 1.728, 866 $170, 850 1899, 71/95,439,635 9 9B2 Te : : 1 . ! | i I | | ! 3 | | - : | | | | : | _ Hi | ~lT- SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE - OHIO STATE REGIONAL MEDICAL PROGRAMS: RM 00022 5/71 ' FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: The Committee recommended that the RMP be funded at the level of commitment for one year only and that two-stage site visit be made to this Region and other Ohio ! RMPs. The Ad Hoc Panel on Renal Disease believed that two projects (Cadaveric Transplant Program and Pediatric Nephrology Center) were worthy of support, but proposals for Program for Hypertension Detection | and Home Dialysis Program did not meet technical standards. (DIREC? COSTS ONLY) Continuation Commitment Year Request __ Recommendation 03 $714,075 $714,075 1/ 04 $714,495 -0- 05 $586,569 _____-0- TOTAL $2,015,139 $714,075 © Renewal Activities Year Request Recommendation 03 ' $122,068 -0- 04 $ 88,574 -0- 05 $39 ,688 Or TOTAL $250, 330 -0- Supplemental Funding Year Request = Recommendation 03 $996,749 -O- O4 $1,068,808 -0- 05 $1,102,609 ar a TOTAL $3,168,166 -0- Total Triennial Request Year Request _ Recommendation 03 $1,832,892 $714,075 04 $1,871,877 ~0- 05 _. — $1,728,366 On. TOTAL $5,433,635 $714,075 @ 1/ $714,075 is the amount of the original commitment, the new reduced commitment due to RMPS fiscal constraints is $628, 386. OHLO STATE RMP ~2- RM 00022 5/71 CRITIQUE: Since this Region has not received a site visit since December 1968, and since the present triennial ‘application appeared to be primarily a series of outlines which conveyed to the reviewers little "feel" for the Region, the Committee agreed that it did not have sufficient information adequately to judge the current status of the Ohio State RMP. In addition to the staff concerns listed on pages one and two of the yellow summary, it was thought that the — application presented no clear evidence of accomplishments, did not alleviate long-standing concerns regarding the merits of the local continuing education councils, and certainly did not justify any supplemental support for this Region. Further, the NHORMP's poor success record of Council-approved activities caused the Committee to question the adequacy-of the local review process. The reviewers, too, were concerned about the fragmentation of the State among the Northeast ‘Ohio, Northwest Ohio, and Ohio State Regional Medical Programs. In view of the above concerns (and also the sexious problems in the Northeast and Northwest Ohic RMPs), the consensus was that the Ohio State RMP should be supported for one additional year at its commitment of $714,075%with similar holding actions being taken for the NEO and NWO Regions. Each of the three Regions should receive a site visit to conecéntrate on that.program's problems, strengths, and weaknesses. After these three information-gathering visits, a second-stage consultative visit should include the RAG chairmen, Coordinators, sponsoring institution representatives, and other officials of each program to discuss amalgamation of the programs. The one - year continuation of the three separate RMPs, then, is viewed by the Review Committee only as an interim step toward the unification of Ohio. Continuation Commitment: Continuation funds were requested for core and two ongoing activities (Computer-Assisted Instruction and Ottawa Valley Continuing. Education Council). The Review Committee agreed that the new commitment level of $628,386 should be recommended for one additional year to support the conduct of these activities and other approved projects into which the Region chooses to rebudget, within this’ level of funding. activities: Tri- ‘County Continuing Education Council, Coronary Care Unit Training, and Stroke Rehabilitation Training. Although no additional renewal funds were recommended fer these projects, the Region is not prohibited from exercising its rebucgeting authority for their continuation. ° *Recently reduced to $628,386 due to RMPS financial stringencies. roy “ OHIO STATE RMP , ~3- _ RM 00022 5/71 - * Supplemental Support: Supplemental funding was requested for the following: A. ' Developmental Component ~ In view of the dearth of information about this Region, the problems cited above, and the serious concerns about the fragmentation of Ohio among three programs, ~ developmental component funding was not recommended. ' Activation of Approved/Unfunded Projects ~- Supplemental support was requested for the initiation of three projects and core expansion for which previous Council-approval has been given but for which no funds have been awarded: Core Expansion, Greater Portsmouth Area Continuing Education Council, Program to Improve Volunteer Services, and Central Ohio Phonocardioscan Screening. No additional funds were recommended for these activities, although the Region may exercise its rebudgeting authority if it wishes, except for the $110,000 supplement under Core Expansion for the expansion of the program Health Careers in Ohio. In view of the staff opinion that expansion of this program exceeds the bounds of permissible RMPS support the Review Committee recommended disapproval of supplemental monies for health careers activities. Initiation of Nine New Activities - Four proposals for new activities received technical review from the Ad Hoc Panel Program and Pediatric Nephrology Center) were considered worthy of support. However, the Ad Hoc Panel considered that the other two renal projects, Program for Hypertension Detection and Home Dialysis Program, did not meet technical standards and should not be supported with RMP funds. These four proposals are discussed in more detail below. The remaining new activities for which supplemental support was requested were: Development of POMR System in a Community Hospital, Training Program for Medical Social Service Personnel, “Cancer Management Evaluation, Centralized Hospital Pre-Admission Health Evaluation, and Drug Information and Drug Therapy Analysis and Reporting Center. Considering the lack of substantive information about this Region, and the problems revolving around the fragmentation of the State into three separate programs, the Review Committee could recommend no additional funds for the initiation of these new projects. The Region is not prohibited, however, from beginning the activities through rebudgeting, if it chooses, except for the two projects specifically disapproved by the Ad Hoc Kidney Panel. Brief comments of the Panel on the four renal proposals follow: ey * OHIC STATE RMP ~h- RM 00022 5/71 Cadaveric Transplant - The Ad Hoc Panel though the proposal should be modified to reduce the budget by $28,000 from $112,840 to. $84,840, — Pediatric Nephrology Center ~ The Panel though that there was a distinct need for a pediatric nephrology program. ‘The approval by the Panel was only for "seed" money to hire core personnel to initiate a much-needed program, with a con- comitant reduction in the budget from $75,824 to $30,800. Funds budgeted for the salary of a pediatric nephrologist should be utilized only when the applicant agency has recruited and hired such an individual to work on this specific proposal. . Pregram for Hypertension Detection - The Panel considered this proposal to be poorly described and based on nonexistent data. It Jacks background, method, and evaluation. There is no description of follow-up and no control is evident for this program. Home Dialysis Program - It was agreed thatthe proposal does not describe need and fails to define problems. There is no description of facilities or staff, and no coordinator for the transplant program is identified. The pian was considered generally poorly written and thought out. Further, there is no estimate of the number of patients. os. GRB/RMPS 4/23/71 . REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) OHIO VALLEY REGIONAL MEDICAL PROGRAM 1718 Alexandria Drive RM 00048 5/71 P.O. Box 4025 Lexington, Kentucky Program Coordinator: William H.McBeath, M.D. This application requests supplemental funds to support three new operational projects. The Region's Triennial application is due August 1971 and will be reviewed by the October 1971 Review Committee and the November 1971 Advisory Council. Requested (Direct Costs Only) Project # and Title Ql Year 02 Year 03 Year Total #22 - Coordinating Pri- $98,610 = $96,410 $98,360 $293,380 Mary Care for a Rural Population #23 ~- Regional Nursing $89,123 $89,400 $92,000 $270,523 Inservice and Continued Education (NICE) #24 ~ Intensive CCU Nurse Training $52,023 $53,689 $57,448 $163, Lov TOTAL - $239,756 $239,499 $247,808 $727,063 This Region was originally funded at $1,064,195 (d.c.) for its third operational year ending December 31, 1971. However, due to RMP fiscal 1971-72 apportionment this total has been reduced by $88,331 to $1,064,195, The Region received indirect costs of $278,993 for this year which represents an average indirect cost rate of 26%. Staff conducted its review of the Region's application for the third year operational funding in December 1970, and was satisfied that the Region is making progress and noted that ongoing activities reflect the Region's program "thrusts"which were established by mie BAC during 1969 and remaings, “The development and more effective miidvation of health manpoweb for the delivery of tmproved ambulatory we . Cary. Ohio Valley —_ vo Regional Medical Program ~2- ; RM 00048 5/71 oF FUNDING HISTORY (Planning Stage) Period Funded (direct costs) Grant Year 01 : 1/1/67-12/31/67 . $285,506 02 1/1/68-12/31/68 -- $320,092 (Operational Stage) 01 7 1/1/69-12/31/69 $799,195 02. 1/1/70-12/31/70 $1,214,460 03 (current year) 1/1/71-12/31/71 $1,064,195 (of which $25,000-is carryover) 03 Listing of Funding Status. of Core and Operational Projects in Ohio Valley ~RMP ‘ Project Project , Amount supported (d.c.) Number _Title Through 12/31/71 2] Core $338,781 2. Community Health Staff Development $189 , 320 4 . Library: Extension $88 , 332 5 University Continuing Education — — $120,262 Resources 6 Drug Information Service $12,500 7 Automated Multiphasic Screening $200,000 11 Rural Home Care $90,000 13 Advanced Radiologic Technologist $25 ,000* ~ TOTAL ST,064,195** *Carryover funds. This project will be funded through March 31, 1971, at which time financial responsibility will be assumed by the National Center for Health Service & Research Development. *k This amount has been reduced by $88,331. To $1,064,195, however, new budgets based on the reduced amount have not as yet been received by RMPS. SUMMARIES OF NEW OPERATIONAL PROPOSALS Project #22 - Coordinating Primary Care for a Rural Population Requested This three-year proposal is sponsored by the First Year United Health Services of Kentucky and Tennessee, an organiz- $98,610 ation which was created by three community clinics: (1) Clear Ohio Valley Regional Medical Program -3- RM 00048 5/71 Fork Community Development Projects Inc., Tennessee; Lawwell Fork Community Clinic, Inc., Kentucky; and White Oak Health Center, Inc., Tennessee. These three rural clinics which operate on a part-time un- coordinated basis are to be joined into a single health care system to serve the 4,500 people along the Kentucky-Tennessee border. The purpose of this proposal is to strengthen and expand the primary health care system within this target area and to provide a capability for coordinating that system with supportative and specialized service outside the area. To achieve this, the proposal will provide for the training of Full- time nurse practitioners to staff each clinic; the development of a family-centered problem-oriented medical record system; the establish- ment of a central staff to manage the administration affairs of the primary care system; and the use of family health workers to provide an outreach and follow-up component. A University-related dental service program will also be established. Each clinic will be staffed with a full-time nurse practitioner, a health aide, a patient assistant and three or four family health workers. Physicians will be in each clinic two days each week. Cooperative arrangements will be developed with a number of agencies and facilities outside the area. The proposed project activities are related to the Region's "thrust" in that they: 1. Establish a mechanism for coordinating the primary health system of the area Internally and with Che specialized resources found elswhere. Support the. training of nurse praclilioners to serve as the main providers of clinic services. Nm . aw Emphasize the prevention, education and follow-up aspects of comprehensive care. Specific objectives and an evaluation plan are presented. Second Year: $96,410 Third Year: $98,360 Project #23 - Regional Nursing Inservice and Continuing Requested Education (NICE). This proposal is sponsored First Year by the OVRMP in cooperation with a number of State Hospital $89,123 and Nursing Associations, State Nursing Home Associations, Inservice Fducation Groups and Baccalaureate Nursing Programs. Ohio Valley Regional Medical Program -4~ RM 00048 5/71 The proposal was developed in response to the need and interest demonstrated by these health agencies, institutions and organizations to provide continuing education opportunities for nurses in the Region It is designed to coordinate, collaborate and improve nursing inservice and continuing education throughout the region during a three-year demonstratf4on period. , The ultimate goal is to reach every health institution and agency in the Region and to offer expert assistance in evaluating and strengthening their individual educational programs. The program's activities will focus on three organizational levels which will be implemented by a full-time Regional Coordinator and three Area Coordinators: , 1. Local or Individual Institutional Activity: The area Coordinators will provide the inservice and continuing education personnel in each institution with consultation and assistance in (a) establishing effective communication and understanding between the inservice staff and the administrative and service staff; (b) evaluating the program currently underway and recommending and assisting in the development of new elements; (c) identifying local sources that could be utilized to strengthen the institution's program; and (d) applying technique to objectively evaluate nurs ing care so that areas of sub-optimal performance. can be identified and educational programs focused on specifically identified needs may be designed. , 2. Areawide or Multi-Institution Activities: This approach is expected to substantially upgrade service and continuing education among more specialized personnel in smaller institutions; and bring about. more effective and efficient use of personnel and equipment resources. a 3. Regionwide Programs: This phase of the program activity will be organized on a regional basis and will involve the interface between the local inservice groups and the Region's baccalaureate school of nursing. Short-term courses - three to five days -- will be held and will be focused on locally identified needs that are region-wide in nature and will be designed for 30-50 students. Three such sessions were held during the past year and focused on such topics as stroke rehabilitation, development of nursing care plans and leadership and management of nursery service personnel. It is expected that three of the six baccalaureate schools will offer such sessions each year. Second Year: $89,400 Third Year: $92,000 Ohio Valley Regional Medical Program -5~ RM 00048 5/71 Project #24 - Intensive Coronary Care Unit Nurses Training Requested This project is sponsored by the College First Year of Nursing and Health , University of Cincinnati, and seven $52,023 collaborating institutions: College of Medicine, University of Cincinnati’ American Heart Association (Southwestern Ohio); Veterans Administration Hospital Cincinnati, Cincinnati General Hospital, Good Samaritan Hospital, Cincinnati} Ohio Nurse Association and Greater Cincinnati Hospital Council. Proposed is a program to provide short-term courses to prepare the registered nurse in the special knowledge and skills required for nursing in intensive coronary care units so they can assume beginning responsibilities in a coronary care unit. The courses will include theory presentation and laboratory practice at the College of Nursing and: Health as well as supervised clinical practice in the intensive care units of three area hospitals. Each course will be four weeks long and will be repeatedfour times each year for three years. Fourteen nurses will be accepted for each course, 56 per year, or a total of 168 nurses for the three-year period. Second Year: $53,689 _ Third Year: $57,448 GRB / RMPS 3/18/71 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE OHIO VALLEY REGIONAL MEDICAL PROGRAM | RM 00048 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: This application which requests support for three — new operational projects be partially supported as follows: (DIRECT COSTS ONLY) YEAR REQUEST RECOMMENDATIONS lst Year .. $239,756 $98,610 2nd Year 239,499 96,410 3rd Year 247,808 -* 98,360 TOTAL (Direet Costs) $727,063 $293, 380 CRITIQUE: The Committee noted that Ohio Valley RMP will submit its Triennium Application for consideration in the October/November 1971 Review Cycle. Since this optional application included only three projects, the Committee did not have an opportunity to study their potential impact on the entire program. . However, it was noted that Project #22 - Coordinating Primary Care for a Rural Population is an imaginative approach to the patient access problem and is directly related to the current OVRMP "Thrust" priority - "The development and more effective utilization of health manpower for the delivery of improved ambulatory care." On this basis the. project is recom- mended for additional support. With regard to Project #23 - Regional Nursing In-Service and Con- tinuing Education, Committee believed that while it relates directly to the Region's "Thrust" and warrants approval, it does not have the unique qualities which would warrant additional funds. Committee recognized Project #24 - Intensive Coronary Care Unit Nurses Training as the first CCU Training project to be submitted by OVRMP and in fact might be a desirable activity for this Region. OHIO VALLEY RMP -2- RM 00048 5/71 However, it was difficult to see how it relates to the "Thrust" which emphasizes ambulatory care, and it was believed that at- this point in time Regions should be trying to disengage from such traditional continuing education type activities. Committee con- cluded that while this project is not contrary to policy it is not the type of activity which should be encouraged and thus should be approved without additional funds. GRB/RMPS /4/23/71 ' REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD. GRANT APPLICATION (A Privileged Communication) RM 23-03 5/71 Oklahoma Regional Medical Program April 1971 Review Committee University of Oklahoma Oklahoma City, Oklahoma Program Coordinator: Dale Groom, M.D. This region is currently funded at $1,162,157 (direct costs) for its second operational year (which is a 13 month period) ending May 31, 1971. Core is supported at $390,000 (d.c.), 8 projects at $747,657 (d.c.) and Smoking & Health activities (Core) at $24,500 (d.c.). The Region has submitted a Triennium Application that proposes: , I - A Developmental Component II - The continuation of Core and four projects (5,6,8,10) III - The activation of 1 Council-approved but unfunded activity (#4R) IV - The renewal of two activities (#2R,#3R) V - The implementation of 6 new activities (#13-18) VI - The termination of two activities (#9 and Smoking & Health under Core) The Region requests $2,020,565 (d.c.) for its third year of operation, $1,558,717 (d.c.) the fifth year and $1,422,759 (d.c.) for the sixth year. A breakout chart identifying the components for each of three years is presented on pages 2-4 of this summary. One of the proposed new activities (#13) was previously reviewed and — denied support. This point will be elaborated on later in the body of this summary. , While a site visit fs not planned for this Region, a Staff review of the application will be made an attachment to this summary. FUNDING HISTORY _ (Planning Stage) ' Period Funded (d.c.) Grant Year 01 9/1/66-8/31/67 $142,250 02 9/1/67-8/ 31/68 $249,017 03 9/1/68-8/ 31/69 $323,993 Grant Year (Operational Stage) Period Funded (d.c.) Future Commitment (d.c.) ol 5/1/69-4/30/70 $1,074,145 1/ — 02 5/1/70-5/31/71 1,162,157 -+-- 03 6/1/71-5/31/72 |= $839,205 * The indirect cost for the Region for the current year is $273,741 which represents an indirect cost rate of 23.5 ° 1/This award served to incorporate Core, which ‘was being supported as a planning grant, into the operational grant period. REGION Oklahoma CYCLE RM 00023 5/71 BREAKOUT OF REQUEST 03 PERIOD | (Triennium Application) OO rns IDENTIFICATION OF | CONTINUING | ‘PREVIOUSLY { NEW r COMPONENT [ACTIVITIES _iRENEWAL APPR/UNFUN, jACTIVITIES | DIRECT [INDIRECT TOTAL Developmental | | _ 70,000 70,000 | - 70,000 CORE | 645,769 | 645,769 | 141,036 | 786,805 #13 Regional Pediatric Prog. i 242,773 242.773 | 32,613 275,386 #14 Bartlesville Cont. Ed. | | 60,0511 | 60,051 | --- __ 60,051 #15 Ada Cont. Ed. Center i ! 39,929 39,929 --- { 39 929 7 ; ! i } #16 Ada. C.E. Prog. (stroke)] | 77,050 77,050 --- 77.050 #17. Stomal Therapy and i 1 Catheter Care i 63,748 63,748 | 23,261 87,009 | #18 Nutrition & Diabetes | | 82,680 82,680 16,897 99,577 #3R Emphysema Program 118, 247 | - 118,247 | 29,822 148, 069 t ;#4R Enid Cont. Ed. Center | 42,104 ! 42,104 --- 42,104 #2R Coronary Care for Oklahoma, 247,459 | |. 247,459 61,367 308 ,826 #5 Tulsa Cancer Control | Program | 58,200 | 58,200 58,200 #6 Library & Info. Services! 52,674 | 52,674 | 15,933 68,607 a i #8 Mammography ! 114,460 | 114,460 | 43,330 157,790 _ : — ; ' : a q #10 Regional Urology Program: 105,421 | 105,421 23 355 128,776 | : | ! ' i i TOTAL | 976,524 365,706 : 636,231 '2,020,565 |.387,614 toe : ts . LA. _ 3 : : | REGION 9k lL alhtoma CYCLE. RT 00023 35/71 BREAKOUT OF REQUEST ff PERIOD 7 IDENTIFICATION OF CONTINUING | [PREVIOUSLY | NEW 7 COMPONENT ACTIVITIES ‘:RENEWAL 1APPR/UNFUN, ‘ACTIVITIES t DIRECT ‘INDIRECT TOTAL 1 Developmental | 70,000 70,000 70,000 CORE 664,277 | 662,277 | x 664,277 | 1 { { #13 379,964 | 379,944) 379,944 #14 40,711 40.711 --- 40,711 #15 { 39,028 39,028 --- 39, 028 #16 70,853 70,853 =s 70,853. #17 | 88,476 | 88,476 * 88,476 7 i #f3 86,799 86,799 * 86,799 | { 1 i { : #3R 118,629 118,629 x 118,629 i | | | #4R --- jo wee --- --- | | #2R fo eee a --- -- c po Po | ef ee | : t6 [oot | --- = --- : i j #8 “= : ! pose ee = 2 j i ‘. ‘ \ #10 ee _— — _-- | | : : | ) ) | i : ‘ : | | TOTAL ! 664,277 118,629 | 775,811 1,558,717), 1,558,717 BREAKOUT OF REQUEST 05 PERIOD ‘ALL YEARS ALL YEARS. | IDENTIFICATION | CONTINUING | 9 PREVIOUSLY NEW To poo GT ‘ | OF COMPONENT | ACTIVITIES | RENEWAL Z APPR. /UNFUN, | ACTIVITIES! DIRECT | INDIRECT | TOTAL |; DIRECT TOTAL _Developaenta | | 70,000 70,000 2 | 70, 000 ! 210,000 | 210,000 CORE | 690,539 ! 690,539 | * 90,539 | 2,000,585 [2,141,621 #13 : | 343,065 | 343,065 Lb * 343,065 |! 965,782 | 998,395 | #14 | ! 43,341 | 43,341 | -- 43,341 |! 144,103 | 144,103 #15 ! | 39,865 | 39,865 | -- 39,865. | 118,822 | 118,822 #16 | | 73,746 | 73,746 | -- | 73,746 — 221,649 | 221,649 : #17 L | 91,109 | 91,109 i * i 91,109 | 243,333 | 243,333 | #18 | ! | 71,0% | 71,00%! * | 71,094 | 240,573 _| 257,470 #3R ! --- | _ -- : fl 236,876 | 266,698 #4R ! --- | --- -- eee |) a2,104 | 42,104 #2R : aos --- -- --- |: 247,459 | 308,826 #5 ee | --- --- |---|} 58,200 | 58,200 #6 awn | | _— --- | a 52,674 68,607 #8 --- | | --- | a+ + 12. |} 114,460 | 157,790 #10 --- : ! Foss fone} wee dE 05,421 | 1285776 : | | | i | : TOTS? | ; ! 4 i . | | mt 690,539 | 1,422,759 | 11,422,759} | 5,002, 041 * To be negotiated | | ! . . | wv. | . Oklahoma Regional . -5- RM 23-03 5/71 t Medical Program GEOGRAPHY ~ DEMOGRAPHY ~- CHARACTERISTICS: From the beginning this Region has been defined as the State of Oklahoma. 1) Population-2.52 million (as of July 1,1968) a. b. c. 63% Urban 90% White, 7% Negro, 3% Other Median Age-30 years (U.S. average 29.4) 1960 2) Land Area ~ 68,887 square miles 3) Health Statistics: Death Rates by Selected Causes/100,000 ~ 1967, Unpublished | a. b. c. d. e. Heart Disease - 368.8 (slightly higher) Malignant Neoplasms - 157.6 (slightly higher) Vascular lesions - 127.4 (high) General Arteriosclerosis - 19.9 (higher) Diabetes - 21.4 (very high) 4) Facilities: a. b. c. d. e. University of Oklahoma School of Medicine - enrollment 394 Schools of Nursing - 11 (3 college or university affiliated) Schools of Medical Technology 13 Cytotechnology, University of Oklahoma (1) There are 138 hospitals with 19,202 beds 5) Personnel Statistics: a. As of 1967, there were 2,904 physicians (2,483 M.Ds and 421 D.0O.s) for a rate of 119/100,000. b. As of 1966, there were 6,582 total nurses of which 4s 435 are employed. Map of Oklahoma's Major Cities & Population , . , BARTLESVILLE @ Oxlavoma 30,000 - ENID @ 40,000 @ TULSA 280 ,000 MUSKOGEE @ 38,000 @ OKLAHOMA CITY 380,000 7058) Oo Oklahoma Regional oo Medical Program ~6- RM 23-03 5/71 HISTORY & DEVELOPMENT The Region received an initial planning grant of $142,250 (d.c.) for the year 8/1/66-8/31/67. A second year planning grant in the amount of $249,017 (d.c.) was awarded for the period 9/1/67-8/31/68. , A third year planning award of $323,993 (d.c.) for the period 9/1/68-8/31/69. 8 In September 1968, the Region submitted an operational application consisting of ten projects. , [In November 1968 a pre-operational site visit was conducted to the vegion. The team consisted of Henry Lemon, M.D., Elliott Rapaport, M.D., Ralph Ingersoll, Ph.D., and RMPS Staff Anthony Komaroff, M.D., and Patricia “McDonald. The visitors were favorably impressed with Dr. Dale Groom, M.D., who was in the process of replacing Kelly West, M.D., as - Coordinator, noting he has a good background for the position. However, it was evident that Dr. West would still be actively involved in ORMP. The visitors were convinced ORMP was a true Region centering around the Oklahoma Medical Center as the focus of higher medical education in the State and there was evidence of ties between the Oklahoma Medical a Center and its affiliates and the physicians of the surrounding cities and towns, ineluding Tulsa. It was noted that in some cases the ORMP activities extend into other adjacent regions and vice-versa, however, the arrangement appeared to be working well. The visitors observed several shortcomings in the Region, these were: the organization, composition and role of the RAG; the absence of a well-inteyrated plan for the development of the Oklahoma program, the failure to th{nk about getting priorities; the domination of the program by the University; and the need for nurses, hospital administrators, persons from the periphery, ete. to take an innovative role. On the other hand the visitors noted there were capable persons from the periphery who had an obvious Interest in GRMP, and in particular the strong Tulsa group. There appeared to se capable leadership of the program and the excellence of the medical school which represented special categorical strength appeared to indicate the wisdom of providing operational funding. As a result. of the pre-operational site visit the Region became operational on 5/1/69 with an award of $1,074,145(d.c.) for support of Core and nine | operational projects for the period §/1/69-4/30/70. This award served to incorporate Core, which was currently being supported as a planning grant, into the operational grant period. In April 1970 Staff reviewed the Region's 02 continuation appLication. Staff, noting that Dr. Groom is the only full-time physician on Core staff, wax concerned about the degree of avallable physician leadership. ft wan queetfoned why the full-time M.D). posttion of Assoclate Coordinater was still vacant. Concern was also expressed over four of the Core statt positions being filled by retired Air Force Officers who had no prior health related exnerience. It was felt the proposed full-time coordinator for Tulsa area would lend strength to the program but that the functions of the positon needed to be clarified. The appropriateness Oklahoma Regional Medical Program -J- RM 23-03 5/71 of the initiation of a number of feasibility studies was questioned and it appeared as if it was premature utilization of developmental component approach. The responsibilities of the RAG in relation to the feasibility studies were questioned. The functions of Core staff in the initiation, conduct and eyaluation unapparent, and Staff seemed more devoted to initiating a series of pilot activities in prevention. Staff concluded it was uneasy about the developing program in Oklahoma and the influence and direction the Core Staff was executing on ongoing activities. Staff recommended that the continuation application be approved as requested but also that staff visit the region to gather additional information regarding the cited concerns. . The Region received an 02 year award of $1,162,157 (d.c.) for Core and eight projects, with restrictions pending additional information. On July 15,-1970, the Region responded to the major concerns cited in the April Staff Review and for the most part answered them satisfactorily; qualifications for the Tulsa Coordinator were outlined. The decision-making process for feasibility studies were described, and additional insight was provided on Core Staff's functions as they relate to ongoing projects. However, little information was provided as to how the activities of the Tulsa Core Staff would be monitored. On July 22, 1970 a visit was made to the Region by five members of RMPS Frank Mark, M.D., Julia Kula, David Peale, M.D., James Gross, and Frank Zizlavsky. The visitors found overall planning methodologies Staff: i were not sufficiently developed and only recently had a director of planning been hired. The Coordinator felt many of the deficienctes in annlications reeulted from Jack of puidance from RMPS on how to develop apniications., Professional Core Staff monitoring of projects was identified as teing inadequate, as had heen_past progress reports. The visitors believed a large percentage of the monetary resources were going Into the medical centers where there was a general reluctance of some project directors to move project activities from the medical center base into "have not’ areas. The planning, ediomological, health services and other resources of the School of Public Health, which is within a few blocks of the Oklahoma RMP and would be most useful, essentially are not being used. General recommendations resulting from the visit were: l. es That a professional core staff person be delegated responsibility for continuous surveillance and monitoring of each project. That an overall plan for the development of regional planning methodology, based on a systematic approach, be developed, including identification of the person who will have major responsibility. That the Tulsa Area subregional coordinator attend seminars or woreaheps in community health planning and community action ‘leadership type programs and develop and submit a subregional plan to the coordinator. “0 Oklahoma Regional Medical Program -8- RM 23-03 5/71 4, That categorical committees should serve as strong technical reviewers for the RAG. That cooperative arrangements be undertaken between the School of Public Health and ORMP. , oA 6. That the incoming ORMP supplement for additional Core staff be given consideration in view of existing needs. 7.. That the. Region be informed that responsibility for demonstrating program and values of individual proposals rests with ORMP staff, 8. That a chairman of the Cancer Committee be appointed in the near future. 9. Restrictions placed on the 02 year award be removed. In December 1970 Staff responded to those recommendations which, related to the Region. While some questions were answered directly, others (2 & 4) were deferred to the Triennium Application which would shortly be submitted to RMPS. A report on program progress during the first two years of the program is on pages 16-2). PROGRAM PROPOSED IN PRESENT APPLICATION These goals and objectives not radically different from those originally projected (see page 16), their essibility problems -Goals and Objectives: order varies somewhat there is some inkling that the acc are important. Overall Goal: To assure that the highest possible standard of medical “eare is equally available to all citizens of the Region for control of heart disease, cancer, stroke, renal and other major and related diseases deemed to be within the scope of the Regional Medical Program Act, as amended. Sub-Goals: To provide the Region with leadership and guidance in developing and deploying its health resources to control heart disease, cancer, stroke, renal and other major and related diseases. To act, by all appropriate means, as a major catalyst and enabler in the formation and perpetuation of more effective and efficient cooperative arrangements for the delivery of better health care to the citizens of the Region. To explore the future directions of the health care system and to make positive contributions through demonstration and implementation to the evolutionary development of the system. * Oklahoma Regional Medical Program -9- RM 23-97 5/7} Objectives: Develop ways and means of achieving understanding and cooperation among hospitals, educational institutions, voluntary and public health agencies, comprehensive health planning and other groups to improve medical care in the Region. , Promote the life-long continuing education of physicians and other health related professionals within the Region. Encourage the development of adequate health manpower resources to meet needs of the Region. Improve the quality and quantity of the delivery of health care at the community level throughout the Region. . Where appropriate, every action and activity of the Oklahoma Regional Medical Program will include public education and will be directed toward promoting a greater understanding by the citizens of the Region and of “the need for , and means of obtaining, high quality health maintenance and care. Regional Advisory Group: The RAG consists of 53 members. While there is considerable dual representation by many members, representation can be categorized pasically as follows: 1. Practicing Physicians - 12 9. Consumer - 4 2. Medical Center Representation - 3 2-Indian 3. Hospital Administrators - 3 1-Black 4. Health Related Professions - 8 1-White 5. Voluntary Health Agencies - 3 10. State Government - 2 6. Medical Professional Society - 9 1-Planning Agency 7. Educational Institution - 2 | 1ll.. Health Insurance - 1 8. Labor - 2 _ 12. Industry - 2 13. V.A. Hospital - 2 Committees: In addition to the Steering Committee there are 12 working committees which are expected to provide the ORMP RAG with essential guidance and professional expertise in the following specific areas of responsibility. 1. Heart Disease 8. Hospital Services 2.. Cancer 9, Out-of-Hospital Medical Services 3. Renal Disease 10. Continuing Education 4. Pulmonary Disease 11. Multiphasic Screening and 5. Stroke ‘ Automated Data 6. Related Diseases 12. Nutrition 7. Manpower and Education Oklahoma Regional - , . ’ Medical Program ~10- RM 23-03 Review and Evaluation: A flow chart. of review and evaluation is presented on page 22, Subregionalization: Formation of Sub-Regional or Area Planning Groups has been urged by core staff from the earliest planning stages of ORMP, however, being able to offer little incentive or assurance of support to local action groups 4 for planning and development activities, only three such groups have been organized; Ada, Tulsa, and Enid. Two other areas have indicated an interest in forming such groups: Lawton and McAlester and core staff is currently assisting in the effort. Requested First Year $70,000 Developmental Component: The Region sees the developmental component as serving basically two major functions: (1) promoting collaborative and cooperative endeavors among components of the health’ care system through financing of pilot/feasibility studies and . (2) establishing a more adequate data and information base for action planning through up-dating that which is already available and obtaining new and different types of data and information. 4 specific protocol is outlined identifying the roles of core, steering committee and RAG in the promotion, development, and review of requests for developmental support. ‘ Second Year: $70,000 Third Year: $70,000 Core: Core is currently funded at $360,000, for a 13 Requested _month period, which supports an equivalent of Third Year 26 full-time positions: 16 professional and 10 $645,769 secretarial. Request is being made to increase Core staff to an equivalent of 43 full-time positions; 27 professional and 16 secretarial. (See page 14 for outline of current and proposed positions). Fourth Year: $664,277 Fifth Year: $690,539 Oklahoma Regional Medical Program ce 2 RM 23~03 5/71 Project Requests by Disease Categories: Included in these summaries is the priority given each by the RAG. Heart & Stroke Requested Project #2R-Coronary Care Program for Oklahoma - Oklahoma Third Year Medical Center $247 ,459 (Priority 1) This project which is in its 02 and final year of operation was initially funded at approximately '; the original request for 2 years, as a feasibility study. A summary of progress is on page 16. Objectives: Request is being made for which one year of renewed support for this project is designed to create acute coronary care units in hospitals financially unable to develop complete coronary care units. During this year effort will be made to expand coronary monitoring into the northwest portion of the state and into Public Health Service Indian Hospitals. Sixteen new remote coronary beds are proposed bringing the total by completion of the project to 56 to 59 beds. Plans include continuing education programs for physicians, nurses and para-medical personnel. The training of Job Core students as Coronary Care Technicians will continue. Equipment category represents $77,318 of the total budget request Project #16-Ada. Area Continuing Care Program (Stroke)- Requested Valley View Hospital First Year (Priority 8) $77,050 Objectives: To develop a team which will provide rehabilitation services to hospitals and nursing homes throughout the area. Provide a series of stroke workshops and seminars for physicians, nurses, and other allied health personnel in the area. A survey will be initiated to determine more precisely the extent of the stroke problem in the area. Second Year: $70,873 Third Year: $73,746 Cancer Requested Project #5-Tulsa Area Cancer Control Program Third Year $58,200 (Priority 12)This project is currently in its second year of operation, third year committed. support is being requested. A summary of progress Is on page 17. Oklahoma Regional: . Medical Program _ 212- RM 23-03 5/71 Objectives: The most important intent is the continuation of a Cancer Control Clinic in the Tulsa Model Cities Target Area. This clinic screens adults (most negro) over 40 for the 5. most common malignancies and includes instruction of patients being - examined. The project will also provide for the continuance of the computerized registry and the surgical residency training program which provides a mechanism for direct contact with young surgeons planning will be continued with the Hillcrest Medical Center in reference to the rehabilitation center currently under construction. -Project #8-A Regional Program to Promote Early Diagnosis of Breast Requested _Cancer with Special Emphasis on Mammography- Oklahoma Third Year Medical Center $114,460 (Priority 13) This project is currently in its second year of operation, third year committed support is being requested. A summary of progress is on page 17. Development of multiple clinics in remaining quadrants of the state. Continue the training program for resident radiologists at the Medical Center Breast Clinic Continue the affiliation programs for both registered and student radiologic technologists. Initiate an all’ out publicity and community awareness program. Objectives: Project #10- Regional Urology Project with Initial Emphasis on Requested . Cancer of the Prostate - Oklahoma Medical Center Third Year $105,421 (Priority 4) This project is currently in its second year of operation, third year committed support is being requested. A gummary. of progress is on page 18. Objectives: This project is entering its third phase which is to initiate continuing education programs based on data collected in an indepth study of six sample groups of the total project representing different settings of urologic care. The addition of further study will provide correlated information which will be more reliable and specific for continuing education purposes. Public attention to preventive measures will be strengthened by appropriate use of collected data through the areawide Comprehensive Health Planning Program. Project #17 - Stomal Therapy and Catheter Care -— Oklahoma Requested Medical Center ; Farst teat ‘ $63,748 Npiectives: To establish a model Stomal Therapy and Catheter Care we Clinic at the Oklahoma Medical Center which will serve as a training base for Nurse-therapists from throughout the Region, Oklahoma Regional Medical Program -13- RM 23-03 5/71 who will return to their areas, identify local needs and resources, and with assistance of the project director develop local clinics for education, training and service overall objective is to provide optimal care patients with a stoma or indwelling catheter by teaching self-care and continuity of care through coordinated community resources. Second Year: $88,476 Third Year: $91,109 Related Diseases , Requested First Year Project. #3R - A Regional Emphysema Program - Oklahoma Medical $118,247 Center . : (Priority 9) This is a renewal request of a project which was approved and funded for 2 years and is currently in its final year of operation. A summary of progress is on page 19%, Objectives: Maximum effort will be made by the four teaching and center which were established during the first year to provide more training and intensive education programs for the health professionals. Programs will be conducted for physicians, nurses, inhalation therapists, and other professionals in the units and in pulmonary function laboratories. Practicing physicians and nurses will work and train in the established units for a week or more at a time. Second Year: $118,629 Project #13- Regional Pediatric Program with Initial Emphasis Requested on Indian Children - Oklahoma Medical Center First Year $242,773 (Priority #10) This project was previously reviewed by Committee and Council and support was not recommended. Its relationship to the ongoing program was not clear, it was training physicians with only two-year commitments and training would involve sophisticated equipment which. would not. be available to the physician in actual practice. Objectives: Emphasis will be on Indian population. Visits will be made by specialists in pediatrics nursing and nutrition to Indian Health Service Units for consultation with and teaching of IHS medical officers, nursing and dietetics staffs of the Service Unit Hospitals and health centers, and the Community ‘Health Representatives who serve Indians in their communities and homes. The training program for IHS medical officers will be coordinated with the activities of the local pediatricians who provide consultation to Indian hospitals under contract with IHS. Delivery of health care and nutritional education to the Indian population will be provided through expansion of the Community Health Representative Program of IHS-and development of a training program for CHR's. Sixteen new CHR's will be supported by the project. Education in nutrition will be directed to all members of the health team, particularly CHRs Neonatal Care Centers and Pediatric Oncology Centers will be Oklahoma Regional bo, Medical Program ~14- RM 23-03 5/71 , established in outlying community hospitals. Urologic and cardiac screening will be expanded. Second Year: $379,944 Third: year: $343,065 Requested Project #18 - Nutrition and Diabetes - Oklahoma Medical Center First Year $82,680 (Priority 14) This project is an expansion of a project by the game title which has been funded during the first two operational years. A summary af Project #9 is 4 on page 19. ° Training and recruitment of non-professional dietary manpower for smaller institutions. Advanced training for food service supervisors. Provide dietetic consultation to smaller hospitals to include development and distribution of resource and continuing education material. Demonstrate out-patient diet ' counseling services. Objectives: Second Year: $86,799 Third Year: $71,094 Education - General Project #4R ~. Continuing Education Program for Enid Area - St. Mary's Hospital (Priority 2) Renewal of this nroject has heen previously approved by Committee and Council but has not been funded, A summary of project to date is on page 20. Objectives: Develop ways and means of achieving cooperation in continuing education endeavors among hospitals, educational institutions, and other groups. Promote life-long continuing education of physicians and other health-related professionals through: 1) improved regional communication in personal contact, T.V., radio, print, etc., 2) continuing education programs, 3) extension of educational resources; Oklahoma Medical Center teaching hospitals and institutions, 4) development of self-education programs. Project #6- Library and Information Services - Oklahoma Medical Requested Center _ First year $52,674 (Priority 11) This ongoing project is requesting 03 year committed support. A summary of vroject is on pape 30, Vufectives: Tuprove information services to physicians and other health professtonals In the Region by being immediately responsive to requests for medical information. Aid physicians and other health professionals in the rural areas. Increase the scope of information services and the speed of their delivery. Provide jon of untrained hospital librarians and consult continuing educat Oklahoma Regional Medical Program -15- RM 23-03 5/71 with hospital administrators in an effort to upgrade hospital libraries. Project #14 -Continuing Education Center for Bartlesville Area~ _ Requested Jane Phillips Episcopal Memorial Medical Center. First Year (Priority 6) $60,051 Objectives: Establish a mechanism for providing continuing education for health professionals in a basically rural area of Northeast Oklahoma. Modalities employed would consist of teleconferences, seminars, workshops, video-tape programs and a regional TV network. Promote communication and cooperation among various individuals, institutions and agencies which will lead to joint efforts to meet mutual problems of continuing education. Increase communication between the Oklahoma Medical Center and local health-related professional and institutions. Improve public and patient education. Second Year: $40,711 Third Year; $43,341 Project #15 - Ada Area Continuing Education Center - Valley Requested View Hospital First Year (Priority #5) $39 ,929 Objectives: Establish a mechanism for providing continuing education for health professionals in a basically rural area of Southcentral and Southeastern Oklahoma Modalities would include: a telephone network with visual aid support, indepth workshops and seminars, a health science library, a tie-in to closed circuit television system for higher education in Ardmore. Promote communication and cooperation among various individual institutions and agencies which will lead to joint efforts to meet mutual problems of continuing education. Increase communication between the Oklahoma Medical Center and local health related professionals and institutions. Improve public and patient education. Second Year: $39,028 Third Year: $39,865 Oklahoma Regional . - oe Medical. Program -16- RM 23-03 5/71 ORIGINAL OBJECTIVES OF PROGRAM AT TIME OF OPERATIONAL APPLICATION .. Provide: leadership « and | guidance in developing and deploying the Region's health resources to control heart disease, cancer, stroke and realted diseases. o b. Yo assist the grantee insititution, the University of Oklahoma Medical Center, in effectively discharging its responsibilities to: Q) Develop and promote cooperation between the many components . . of the health care delivery system to improve medical care throughout the Region. : (2) Promote the life- ~long continuing education of physicians and health-related professions. (3) Increase the standards, efficiency and effectiveness of medical care at the community level and make more widely available the potentialities of medical science. (4) Utilize all the resources at its command in collaboration — with the physicians, community hospitals and voluntary health agencies of the State. (5) Provide the intellectual environment and incentives for attainment of the above objectives. c. To act as a major catalyst In the formation and perpetuation of a more effective and effictent cooperative system for the delivery of better health care to the citizens of Oklahoma. a * Projects Projects supported during the first two years of operation are summarized by category as ottows: Heart Project #2 - Coronary Care Program for Oklahoma - Oklahoma Medical Center Funded Perlod: 5/69-5/71 01-$190,000 02-$199 ,600 OLjectives: Create acute coronary care beds in hospitals financially unable to develop complete coronary care units. The program calls for the development of 14 "central monitoring units" (CMUs) in larger urban hospitals. The CNIUS will monitor electro- cardiographic tracings relayed continuously be telephone lines from Oklahoma Regional © Medical Program -17- RM 23-02% 5/71 patients in 31 smaller hospitals "remote stations". Training programs are included for physicians, nurses, and allied health personnel. Achievements: (The project was funded only as a feasibility study at approximately ¥s the original request) By the end of 1970, 17 remote coronary care beds located in 12 small community hospitals were being monitored by trained personnel in 6 central monitoring hospitals. By November 5, 1970, a total of 303 patients had been remotely monitored. Preliminary statistical - results indicate reduced mortality rates can be expected. By the end of the current operational year 40 to 43 remote beds will be operational. Future Plans: One year renewed support is being requested in this application. Cancer Project #5 ~ A Cancer Control Program for the Tulsa Area Funded Period: 5/69-5/71 01+$70,000 02-$50,000 (approved for 03 year) Objectives: The project proposed a series of activities including screening of the disadvantaged population in Tulsa coordinated city-wide tumor registry system, coordinated continuing education among the three hospitals, and rehabilitation. Achievements: The project has served as a catalytic agent to involve numerous agencies in the problem of cancer. The computerized tumor registry has succeeded in providing feedback on patients to their physicians. Specific patient screening procedures have been established to the point where with the additional $50,000 from Model Cities, 10% of the North Tulsa Target Area, population over 40 will be screened for cancer in the coming year. Areas of agreement have been achieved among Tulsa hospitals on acceptance of indigent patients generated by the North Tulsa Clinic. Future Plans: Committed support for the 03 year is being requested in this application. Project #8 - A Regional Program To Promote Early Diagnosis of Breast Cancer with Special Emphasis on Mammography - Oklahoma Medical Center Funded Period: 5/69-5/71 ~$100,000 02-$100,000 (approved for 03 vear) Objectives: To establish a Regional Mammography Unit at the Medical Center which would serve as a focal point for perfecting techniques and training personnel to develop other units within the Region. Evaluation of the capacity of specially toward nurses Oklahoma Regional | Medical Program ~18- RM 23-03 5/7) to perform physicial examinations of the breast and mainmography screening was planned. A training program for radiological residents ‘in mammography was to be instituted the 3rd year. Mass mammography screening was to be initiated utilizing a mobile unit. Achievements: A mammography unit has been established at the Medical Center and by the end of the 02 yearsnine outside areas will be doing mammography on a varying scale. Radiologic residents are being trained with regular rotation through the mammography unit. A program has been instituted for training : radiologic technicians. All woment who are over 35 years of age are routinely scheduled for mammography. Training of state physicians is conducted through the medical journals, films, exhibits and posters. ' Future Plans:° Committed support for the 03 year is being requested in this application. Project #10 - Regional Urology Program with Initial Emphasis on Cancer ‘of the Prostate - Oklahoma Medical Center Funded Period: .5/69-5/71 ; ; ' Q1-$75,000 02~$79,400 (approved for.the 03 year) | Objectives: Create a consortium of 13 urologists, each of whom would coordinate project activities within his own subregion and to appraise local facilities, resources, manpower and medical practices as they relate to the diagnosis and treatment of cancer of the prostate. Analysis of hospital records and tumor registries - with follow-up on all cases was planned to identify the local needs for continuing education. Achievements: With the support of the Oklahoma State Urological Association a summar pre-test with eleven medical students was completed using protocol forms designed for computer analysis. The material representing over 900 clinical cases plus mortality data indicated the feasibility and value of such a regional project. The permanent field staff of registered nurses who were trained in abstracting information from records, made contact with each of their subregional hospitals. A total of 2,264 cases of cancer of the prostate were identified in 220 hospitals. Evaluation is being made of six representative groups of different urologic care settings in the Region. The number will represent approximately a 15% sampling of the total 2,262 cases. _ Future Plans: Committed support is being requested in this application for the 03 year of operation. Oklahoma Regional Medical Program -19- RM 23-92 5/7) Related Diseases Project #3 - A Regional Emphysema Program - Oklahoma Medical Center Funded Period: 5/69-5/71 01~-$150,145 02-$142,145 Objectives: A Regional Emphysema Unit would be established at the Medical Center and would serve teaching and demonstration purposes. It would be available as a consultative and educational resource to community hospitals. Improved patient care would be achieved by recruiting and training personnel, developing continuing education programs, establishing collaborative relationships, improving and expanding screening activities. Achievements: Three new pulmonary disease specialists have been recruited into the state to fill key hospital teaching positions in affiliated hospitals. Three model intensive respiratory care units have been established (Oklahoma City, Tulsa, and Stillwater) and serve as intensive training units. A screening program employing spirometry is being employed at the Medical Center. Education and Training is carried out through model units, clinics, workships and seminars, over 1,700 health professionals have participated. Future Plans: Renewed support is being requested in this application for a 3rd year of operation. Project #9 - A Regional Program in Nutrition and Diabetes - Oklahoma Medical Center Funded Period: 5/69-5/71 01-$29 ,000 02-$29 ,000 Objectives: To improve the care of diabetic patients by improving the quality and quantity of services at the community level and to improve the quality and quantity of nutrition services in hospitals and nursing homes, emphasizing patients having categorical diseases. The goals would be achieved through a series of continuing education courses for physicians, nurses and dieticians. Achievements: Seventy-seven people were recruited and trained as food service supervisors and will serve in smaller hospitals of sparsely populated areas. An extensive program of continuing education was carried out for professional dietitians and supporting health-related personnel. Thirty workshops were ronducted at 9 different locations, involving 2,000 health workers In 15,000 education hours. Ov lahoma Regional , Medical Programs : -20- RM 23-08 5/71 Future Plans: Terminating - A plan has been developed to exploit _ the progress to date with a new 3-year program, a majority of which would be financed by cooperating groups other - than ORMP. Kducation -General Project #4 - Continuing Education for the Enid Area ~ St. Mary's Hospital - 4 Funded Period: 5/69-5/71 01-$35,000 02-$41,000 (approved as a ’ renewal for an 03 year but unfunded) Objectives: A prototype "medical education center" would be established. The surrounding counties with eight participating hospitals would be included. Continuing education modalities would include video-tape, and 10-tape, library resources, self-instructional material films, conference-type telephone communications, and short courses. -The project seeks to demonstrate the feasibility of such a subregional "center'’.and hopes to. develop a network of similar centers. Achievements: During a fourteen-month period, 55 physicians' tele- conferences have been conducted. Out of 150 physicians in the area, an average of 46 participated in each conference. A total. of 10 day-long physicians' seminars were held with an average of 22 participants. Dial access tapes have held for nurses, 10 for laboratory technologists and 3 for dietitians. Sixteen seminars were held for nurses. |- Future Plans: This project has previously been approved as a renewal (4R) and support is being requested in this application. Project #6 - Library and Information Services - Oklahoma Medical Center Funded Period: 5/69-5/71 , 01-$49 ,000 02-$49,000 (approved for 03 year support) Objectives: Through the Medical Center Library, this project seeks to improve library information services by increasing the speed of delivery, and improving the relevance of the information retrieved. The program will be expanded to three model programs involving five hospltals in Oklahoma City, Tulsa and Enid. The program would promote knowledge of the fmproved library facilities among the medical community. Oklahoma Resional Medical Prorrams ~21- RM 23-02 5/7) Achievements: [tems of information being sent out have increased from 500 per month in January 1970 to 900 per month in November 1970. Health professionals using the service tend to come back. Workships are conducted to train part-time individuals . in change of hospital libraries throughout the state, 96 have attended “to date. Cooperative relationships with other hospitals have been strengthened. Future Plans: Request is being made in this application for 03 year committed support. Project #7 - Regional Program of Public Education on Smoking and Health Funded Period: 5/69-5/71: (Under Core) 01-$12,00. 02-$24,500 Objectives: This project would merge the efforts of ORMP and the Interagency Council on Smoking and Health. ORMP would support a coordinator and the Council would support necessary staff. Achievements: Anti-smoking messages have been publicized through ; printed material, radio, television, speakers bureaus, exhibits, etc. OFFICE PROGRAM REVIEW S EVAL: TRIENNIUA NAT’. COUNCIL DECISION _RMPS_.} on « 7 __ \ councih fy NATIONAL ARIIERSASY, pRIOAITIES EVALUATION! GUIOANGE REVIEW_ A @) SG DECISION Goatss OBO Tved PROPOSALS | FINAaG ‘bRaPT Rae onnirce cs PROPOSE in OFFICE OF ‘ [PHoRESdtowan fevirw 4 Sygate Jeuipauee ow "any (i L COORQRATES [| *Srcentes Krsusat & EyAvvariow itt . FINAL * © OPAFT* (CORE erarF COGROINATIS Wirt c RAG PConess TCE. CORE PAPER YN REVIEW \ STARE PP. PARATION OF g Review Fratat DRAET EvaLuaTioNn 2 CORE STAFF : i —— To evaiveare | ee nee oe enema 1... vet Conncentstes To “ COnMIrree (nas) ae cy SUB-RESIONS & COOFLIWAIING AGEnCciesS REvitw & / EVARVAT */ f OrFite “oF Rivis OR EVALs. ros Praweiire . ) eee creuce wl? cone stare | Mis to ee Ce Su - e |r Review & P “ EVALYATS . . REGIONS a « le nee core grace} > a ae ADMIUISTFAL TE “Lh _ oOo PREPARATION _. fem yc / OF . too oFoensetin cae GRanr REO ST i . ‘ . . PRosecT . lt . —— PROPOSALS Corarrs) .-- Wee ee @ 3ilVid ©) @ , 2 Honirork h 4 Conds, EVALVATION EVALUALE Cone. | OFFICE OF STAFE REVIEW “Coord Tio oO ——_—— eatjonar 4 22 J oP PROJECT PROGRAM k.. ComPone hrs AP Pi ROves NATIONAL REVI . SYSTEM core stare | GEWw CONSOLIDATE Linea — FINAL Sp REGION XT REPORT DALLAS aZRAG - PECISION > . ON Proposals YO Ja MAINIy LLvft WA dW YO MO 14 NO eee oe. ' N nN _t Oklahoma Regional] 9 Medical Programs ~+23- RM 23-03 5/71 Summary of operational projects currently being supported by Oklahoma /RMP Funded 2nd Year d.c. Project Title and # . (5/1/70-4/30/71) #1 - CORE . $ 360,000 #2 - A Coronary Care Program for Oklahoma 199,600 } #3 - A Regional Emphysema Program for Oklahoma 142,145 #4 - Continuing Education Program for the Enid Area 41,900 #5 - A Cancer Control Program for the Tulsa Area 50,000 #6 - A Regional Program to Improve Library and Information Services 49,000 #7 - A Regional Program of Public Education on Smoking and Health (Core activity) 24,500 #8 - A Regional Program to Promote Early Diagnosis of Breast Cancer with Specia] Emphasis on © Mammography 100,000 #9 - A Regional Program in Nutrition 29,000 #10 - Regional Urology Program with Initial Emphasis on Cancer of the Prostate 79,400 ]- month Projects 57,512 extension (5/1/70-5/31/70) Core 30,000 TOTAL $1,162,157 All of the operational projects submitted by the Region were approved and are currently funded. "A. s Date: i Reply to Atin of: DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE . PUBLIC HEALTH SERVICE . , HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION March 30, 1971 Subject: Staff Review of Non-Competing Continuation Application from Oklahoma Te: Regional Medical Program, 5 G03 - RM 00023. Director‘('\\ Regional ‘Medical Programs Service | 1 QQ THROUGH: Chairman of the Honth)>} c OP . . . Chief, “rants Review Branch Chief, Grants Management Branch be Acting Chief, Regional Development Branch - RECOMMENDATIONS : 4 lJ. The Region not be considered for three-year support at this time but that RMPS offer extensive assistance to the Region in preparation for resubmission next year. 2. The Region be awarded the new funding level of $738,500 for its third year of operation, to continue Core and Projects #5,#6,#8,#10. 3. That the Region be encouraged to rebudget into core as seen fit, to advance its program planning to correspond more with new philosophies, and to identify needs, objectives and projects more specifically and in terms of a total program. 4. In line with the first recommendation, a site visit team, including a Committee and/or a Council member, ot other persons of equal clout, visit the Region as soon as possible, preferably before the ena of July, in order to provide much needed guidance in the areas of; the new and broadened philosophy of RMP, assessment of needs, establish- ment of objectives, and program evaluation. . Staff sees this as a critical need for the Region in preparation for resubmission of a Triennium Application next year. REQUEST: Oklahoma Regional Medical Program which is in this 02 operational year (5/1/70-5/31/71) has submitted a Triennium Application consisting of: I - A Developmental Component II - The Continuation of Core and Four Projects III - The Activation of One Council~Approved but Unfunded Activity IV - The Renewal of Two Activities V - The Implementation of Six New Activities VI - The Termination of Two Activities ” WELLE yg Ata UD 4 The consolidated budget requests for each of the three years are as follows (direct costs): 3rd Year 4th Year 5th Year TOTAL Core $645,769 $664,277 ~~ $690,539 $2,000,585 Projects | $1,304,796 824,440 662,220 2,791,456 Developmental 70,000 76,000 70,000 210,000 TOTAL $2,020,565 $1,558,717 $1,422,759 $5,002,041 Oklahoma RMP, when annualized, is currently being supported in its 02 year at $360,000 (d.c.) for Core, $24,500 (d.c.) for smoking and health activities under Core and $690,145 (d.c.) for eight projects, totaling $1,050,145 (d.c.). It has a commitment of $839,205 for Core ($360,000) and Projects #5,#6,#8,#10 ($479,205). REVIEW: The Region has chosen to request triennium support now, at the conclusion of their 02 year, rather than wait an additional year and request triennium support at the end of their 03 year. Since the region is not scheduled for a site visit, it will be necessary for Committee and Council to make a general assessment of the program based entirely on the application. ‘ Staff agreed the function of their review should be to make observations and recommendations to be referred to Committee and Council. OBSERVATIONS: The overall program goals and objectives remains basically the same as those established for the first three years of operation. They are largely oriented toward education and training activities, and are vague, non-specific and immeasurable. They do not appear to be based on'specifically assessed needs nor do they relate to identifiable time-frames. They are so broad and general, so - as to be applicable to any type of educational project. The functions of the Steering Committee, are. unclear especially its relationships to the RAG in policy-making and development of goals. It is difficult to seethe need for 13 different categorical committees in a Region having the limited activities of Oklahoma and there is some question as to the degree of their involvement. While it appears some. of these committees have promoted the development of particular projects, there is no evidence that those projeets relate to an overall pre-established specific design or set of objectives. Rather, the projects appear to’ be generated on a random basis. One exception is the continuing education program designed to develop continuing education centers in more rural communities. The review process appears functional in that criteria are established for technical review by both categorical committees, and the. RAG. While the RAG also reviews projects as to their relationship to the overall objectives this process appears superficial, in that, the objectives encompass such a broad spectrum practically any education.type project will qualify. There appears to be established procedures for Staff monitoring of ongoing projects and in addendum material there is evidence of relative effectiveness. Core as organized is highly oriented: toward educational activities and categorical diseases as is the. overall program, a fact which. staff believes. reflects on the progressiveness of this Region. It appears the Region Director,RMPS - Page 3 is not taking into consideration new trends within RMPS and has not broadened the scope of its program, ner its core st caff, along the lines of the new philosophies. Staff expressed concern based on this observation that while the organization of Core as proposed might have been appropriate for the program-a year ago, it may not be desirable for the future and that having once adopted the proposed” organization pattern it would be inflexible or awkward-to change. It was noted that since this Region's last visit in November 1968, Core has been reorganized twice. The problem of acquiring an M.D..as Associate Coordinator no longer exists, in that the position has been eliminated. Staff, recalling the. recommendation of the staff members who visited the Region in’ July, 1970 and felt this position to be of extreme importance and needed to be filled as soon as possible, expressed. concern over this new development. In the past the responsibilities of this position have to a large degree fallen to the Assistant Director, a non-physician, who subsequently became overburdened with work. Under the new organizational plan it appears this situation will be perpetuated. In addition, Staff questioned whether the Assistant Director should in fact be the Chairman of the Council. on Planning, Review and Evaluation. With the development of only three subregional planning groups, Staff believed. the RAG members should be encouraged to take the lead in- developing similar groups in their respective communities. In view of the above observations and the fact the Region is not to be site visited, Staff concluded ORMP should not be considered for — Triennium Review at this time but rather that. RMPS offer extensive assistance to the Region in preparation for another attempt next year, Fee ot William S. Reist Public Health Advisor Grants Review Branch Regional Medical Programs Service a fie ; AS. Greats lel lela Lo , ma if cong seat é e A (tse fn ” ay Signature ¥ fp Participants in the Oklahoma Type V were as follows: Leah Resnick-Regional Development Branch — Margaret Hulburt ~ Allied Health Section . Joan Ensor - Program Planning And Evaluation Frank Zizlavsky - Regional Development Branch Rod Mercker -— Grants Management Branch Judy Silsbee - Grants Review Branch Bill Reist - Grants Review Branch GRB/RMPS SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE OKLAHOMA REGIONAL MEDICAL PROGRAM RM 00023-0603 5/71 . FOR CONSIDERATION BY. MAY 1971- ADVISORY COUNCIL RECOMSENDATTONS : . Year: Request (Direct Costs) Recommendation (Direct Costs) 03 $2,020,565 $913,500 04 1,558,717 ~0- 05 1,422,759 ~O-~ TOTAL $5,002,041 $913,500 1. Approval of committed eupport ($738,500 direct costs) for Continuation of Core and projects #5, 6, 8, 10, for the 03 year, i/ © 2;. Approval of Project #2R, at a reduced level of $175,000, , (direct costs), 3, Approval of renewal project #3R and six new projects, #3~ 18, without additional funds. 4. Non-approval of the Developmental Couponent, 5, A site visit be made to the Region in order te determine its current status, to study effects on patient care of ongoing ectivities particularly its cancer and respiratory disease areas, and to provide guidance to the Region for resubmission of a triennium application, 1/ Committee concurred with Staff's recommendation, from its preliminary review, that the Region be approved for committed support. CRITIQUE: While the application as submitted by ORMP is vell presented on paper, Committee, in the absence of a site visit, had anxieties abovt what ig really happening in che Region, pericularly in view of the folloving observations OKLAHOMA RMP ~2- : RM 00023 The goals and objectives were considered vague, non-specific and immeasurable. They do not appear to be based on specifically assessed needs, nor’ do they relate to identifiabie time frames, Together with the projects, the goals and objectives being proposed represent a program highly oriented toward education and training, activities which are not consistent with current RMP trends. There does not appear to be an effort to stimulate projects which relate specifically to objectives; rather projects appear to be spontaneotisly generated on a random besis-and only coincidentally relate to stated objectives, The functions of the Steering Committee are unclear, especially its relationships to the RAG in policy making and development of goals. The reviewers weré not convinced the proposed organization of Core~ Staff would be appropriate for the future. Noting that RMPS Staff ad coneerns about the Coordinator, Associate Coordinator and the Assistant Coordinator positions, their responsibilities and work loads, Committee believed these concerns should be clarified prior to approval of a Triennium Application. In the absence of more than three subregional planning groups, it was difficult for Committee to understand the involvement of the more rural communities. ; “While projects were not reviewed in detail, some concern was expressed over the cancer and respiratory disease aspects of the progran, Diseppointment was expressed over the progress of the Tulsa Cancer Program, while the Emphysema Program appears highly over budgeted, Although Project #2R - Coronary Care Program appears to have progressed at a satisfactory rate and warrents additional support, Committee did not feel RMPS should be previding support for large purchases of equipment, It, therefore, recommends additional support for this project be limited to $175,000. Also the apparent absence of financial contribution by the Indian Health Service to the Regional Pediatric Program (Project #13) was questioned. ” s re - ~ fhe Region's relationship with the Medical School is unclear and some question was raised as to whether ORMP is being used, Committee concluded that many of the areas around which concern was expressed are basic to the functions of a viable RMP. In view of this, Committee agreed with RMPS Staff that the Region has what appears te be some serious weaknesses, which need to be rectified prior te the re~submission of a Triennium Application next year. It was proposed a site visit be made to the Region in the near future to obtain a better understanding of the Region and provide needed guidance, : GRB/RMPS /4/23/71 REGIONAL MEDICAL PROGRAM SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) PUERTO RICO REGIONAL MEDICAL PROGRAM RM 00065 5/71 Post Office Box M.R. April 1971 Review Committee Caparra Heights Station Puerto Rico 00922 PROGRAM COORDINATOR: Cristino Colon, M.D. This region, currently in its first year of operation, is funded at a level of $958,163 direct costs. In addition the region has received $112,414 of indirect costs which represents an average indirect cost rate of 28.6 percent. , In this anniversary application the region has requested for its second year of operation $1,136,364 d.c. for support of the following activities: I. The continuation of Core and seven ongoing projects ($958,163). II. The implementation of two new projects ($82,953). III. A Developmental Component. ($95,448). (Attached on the back of the summary is a chart identifying the components involved with the above items.) Following are the key issues identified by staff in their review of the continuation application. 1. The need for better geographical representation, lower economic consumer and Model Cities program representation on the RAG. 2. The need for RAG to assume leadership and give direction to the PR-RMP. 3; The increase of Core from 29 to 44 positions, 4, The expansion of Task Forces to include allied health personnel. , 5. The lack of interrelationship between the task forces, RAG, Planning Committee and Core. (Attached on the back of the summary is a copy of the memorandum of staff's review of the continuation application.) Puerto Rico RMP -2- RM 00065 5/71 FUNDING HISTORY (Direct Costs Only) Grant Year . Period oo Funded Planning Stage SO . SO, ; ol: 6/1/68 ~ 5/31/69 - $194,839 02. 6/1/69 - 5/31/70 194,097 02S - 6/1/69 - 5/31/70 94,281 Operational Stage ol 3/1/70 - 2/28/71 Core $320,081. Projects 638,082 Total $958,163 GEOGRAPHY AND DEMOGRAPHY © Puerto Rico, the easternmost of the Creater Antilles, and fourth largest island in the Caribbean area, is bounded on the north by the Atlantic Ocean and on the south by the Caribbean Sea. The Capital city, San Juan, lies some 1,690 miles southeast of New York City | and 1000 miles southeast of Miami. The island of 3,435 square miles, roughly 100 miles long by 35 miles wide, is characterized by a fertile coastal plain covering about 1/4 of the land area, and an east-west running range of mountains. Two of the three larger out~ lying islands are constituted as municipal governments. Rivers are numerous, though of no importance in navigation. The northern coast, due to prevailing winds, has an abundant rainfall, the same as the central mountain range, with peaks above 1,000 meters. In contrast, the southern coast is rather arid, traditionally depending | on irrigation of single crops. Sugar cane, coffee, tobacco, green and starch vegetables and fruits, mainly citrons and pineapple are the principal crops grown on 56% of the land that is tillable. Population: 1970 estimate - 2,947. Approximately 51% urban Median age: 19.71 years. (U.S, average 29.5 yrs.) Density: 760 per square mile Land Area: 3,435 square miles Health Statistics: Mortality rate for heart disease - 147.9/100,000 (low) - Rate for cancer - 88.4/100,000 (low) Rate for CNS vascular lesions - 56.4/100,000 (low) Facilities Statistics: University of Puerto Rico School of Medicine - 4 year school, enrollment of about 301. 4 Puerto Rico RMP -3- RM 00065 5/71 University of Puerto Rico School of Public Health - accredited, enrollment approximately: 384. 10 schools of nursing, 7 are at hospitals, 3 at colleges or universities (2 of them are degree programs). Two schools of medical technology (Department of Health, Institute of Health Laboratories and the University of Puerto Rico School of Medicine) one school of cytotechnology. 138 hospitals in Puerto Rico with 11,872 beds (49 private, 58 Puerto RicoHealth Department, 31 municipal) Personnel Statistics: 2,791 physicians (approximately 1/1000 population) 4,400 graduate nurses (approximate) The economy has shifted from agriculture to a more diversified base. An idea of increasing diversity of manufacturing may be gathered from the fact that manufacture of sugar products represents 4.9 percent of manufacturing income compared to 35 percent in 1940. Tourism is a steadily growing sector of the economy, with total related income cost reaching around $155 million. The Puerto Rican people have benefitted greatly from the aforementioned expansion achieved since 1940. Life expectancy has increased from 46 years to 70 years and the crude death rate has declined from 18.2 per thousand to 6.5 per thousand, somewhat less than the U.S. average. In Puerto Rico there are still two systems whereby the population utilizes health care services;‘the private and the public or govermental systems. It is estimated that 40% of the population utilize private medical and hospital services and 60% utilize the public services. Between30% and 40% of the population is covered by some type of health insurance. An unknown proportion of the population uses private Services at times and public services at other times, depending basically on its economic conditions at the time and on the nature of the illness involved. About 41.4% of the general hospital beds in the island are located in private hospitals. Of these, 17.2% are in private non-profit hospitals and 24.2% in private proprietary hospitals. Most private proprietary hospitals are owned and operated by physicians. The private hospitals for the most part are located in the main cities - San Juan, Ponce, Mayaguez and Humacao,. Private hospitals serve, not only the population in the municipality where they are located, but also receive patients from neighboring municipalities. The public medical and hospital services are administered by the Puerto Rico Department of Health, the municipal governments and Puerto Rico RMP -4- RM 00065 5/71 - other state agencies, i.e., (Workmen's. Compensation). Basically, the, . municipalities have the main responsibility for the provision of health care to the needy. There are seventy-five municipalities ranging in size from 7,000 to. 500,000. The Commonwealth Governments, however, complements the municipal care system. Through arrangements and. agreements with. local governments, public health services - preventive and curative - have been organized into a single system operated jointly by the Department of Health and Municipal Governments; the Department assuming full responsibility for technical and professional service in practically all municipalities, except San Juan. In each municipality, there is a health center. It includes a hospital unit (usually one bed per 1,000 inhabitants), general out-patient facilities and the public welfare unit. In 45 of the 75 municipalities ad hoc buildings have been erected to house these health and social welfare facilities. A regionalized program of medical care developed over the past ten years has resulted in the development of nearly 80 regional health centers and community hospitals,. and the formation of five regional health districts, to be condensed to three major areas (northeast; — south, and west). HISTORY . . In September, 1967, Dr. Nigaglioni, Chancellor of the Medical Science Campus, University of Puerto Rico convened a meeting of leading Health Professionals in Puerto Rico to determine appropriate steps for implementing PL 89-239 in Puerto Rico. This group was designated the "Planning. Committee .". A 20-member Regional Advisory Group was formed and a planning grant application was developed for submission. On October 1967, the Regional Advisory Group (RAG) at its first meeting elected Dr. Adan Nigaglioni, Program Coordinator and approved the Medical Sciences Campus, University of Puerto Rico as the applicant institutions. The initial planning grant. was submitted to RMPS on December 1967, requesting two years support for planning. At the recommendation of the RMPS Review Committee a site visit was conducted to this region in April 1968, by Dr. David E. Rogers, Dr. Henry Lemon, Dr. John R. Hamilton, DRMP and Mrs. Jessie Salazar, DRMP. During this phase of development, there appeared to be a lack of supporting data from private medical areas, as well as evidence of involvement of some of the key public health personnel. Further, it was pointed out that the RAG could be strengthened by the addition of lay members. Council believed that there was no substitute for a full-time person who would be responsible for these RMP activities. This did not imply lack of confidence in the Chancellor, who was the Program Coordinator, but rather believed it imperative for the future program to have at least one person who would devote all of his professional time to it. On the basis of this recommendation, Dr. Cristino Colon was appointed full-time Associate Coordinator in August 1968. Puerto Rico RMP -5- RM 00065 5/71 In May 1968, the planning grant application was approved for two years with the recommendations: greater involvement of medical societies; and recruitment of a full-time Deputy Coordinator. In June 1969, the region's continuation planning grant was approved. Staff noted that the region had progressed noticeably since Dr. Colon becane Associate Coordinator of the program. In addition to committed funds, the region was given a one-year award with unexpended funds for two activities: special studies to assemble new data; and to organize and implement an office of Information and Public Relations, The region's plans were to merge these two functions into the Core activities when it went into operational status. In regard to the region's progress, staff believed the evaluative process to be weak. The categorical Task Forces were named and functional, and there appeared to be a trend toward decentralization with established Committees outside the San Juan Area. In August 1969, the region submitted its first operational application requesting support for Core and 8 projects. A preoperational site visit was conducted in September 1969, by Dr. B.W. Everist, NAC, Dr. Henry Lemon, R.C., Dr. Henry Clark, Consultant, Mrs. Jessie Salazar, RMPS, GRB, and Mr. Frank Nash, RMPS, RDB. Major developments in the health care field reported during this phase of the program involved Puerto Rico embarking on a new and ambitious program to integrate the private and public sectors of medicine. This was instigated with the passage by the legislature of PL 56, permitting payment for services of private patients in Health Department Hospitals, and for indigent patients in private hospitals. Out-patient cost reimbursement is also included. Under PL 81, approved May 1967, seven experiments in five different towns, with different alternatives for financing health care were initiated in an attempt to develop a unified group practice in community health centers. In view of these developments the NAC recommended to the region that a Special Task Force be organized to work with the Commonwealth Heaith Department, the University Medical Center, the Puerto Rico Medical Association, and the voluntary health agencies to make an extended evaluation of progress in the methods of solving primary medical care problems under study. The NAC believed that the RAG was still heavily oriented to the Medical School, although the region indicated that the size of the Group would: be increased. The region was urged to expand its representation from the private medical sector, and explore the possibilities of representation from the new industries located on the island to participate in medical care planning to avoid dislocations between needs and services. The region reported that general by-laws have been adapted and administrative guide- lines for Task Forces were under development. In January 1970, the region received its initial operational award for support of core and six projects. Puerto Rico RMP -6- RM 00065 5/71 The region submitted in July 1970, an application requesting support of three new activities. The Review Committee recommended a site © visit to the region which was conducted in May 1970, by Dr. Henry Lemon, RC, Dr. William S. Fields, Consultant, Mrs. Jessie F. Salazar, GRB, and Mr. Frank Nash, RDB. The region was just beginning to move into full operational status, and was continuing to refine its organizational framework under the leadership of Dr. Cristino Colon, who appeared to be doing an effective job. Planning for RMP program outreach beyond the San Juan medical area had been achieved. The Council indicated that they were impressed by the development of major interest and enthusiasm of lay and medical leadership in Guaynabo, Ponce, and to a lesser extent, in Guayama,. Dr. Nigaglioni, the official Coordinator, appeared to be more and more a background figure, but very valuable for his present planning for health aides and other allied health training in some of the Commonwealth's junior colleges, such as in Ponce. Membership from the lay power structure for PR/RMP R.A.C. members and sub-committee members was still insufficient. The private medical sector in San Juan appeared inactive in planning or participation. Industrial medical facilities developing at the Phillips plant and the Chem-strand plant at Guayama appeared to be outside of RMP planning efforts. In Ponce, on the other hand, there was excellent lay liaison through the Oncologic Clinic, supported by the southern branch of P.R. Cancer Society, and through Dr. Rodriguez's cardiovascular and | renal dialysis and transplant program which has wide and enthusiastic public support (750+ dialyses for 35-40 patients in the past two years). The excellent private medical sector support and participation in Ponce district projects is quite different from the Capital Area indifference and bodes well for effective RMP projects in this area, The nursing profession is still being slighted as an ally in health planning, in traineeships, and in operational programs as instructors. The Council cited the desirability of broadening operational programs to effect a multidisciplinary approach particularly in training activities. Council also believed that a ceiling already has been reached in the 50 - 100% participation of physicians for leadership and development of programs, Future site visitors must carefully evaluate whether salaried time on the job in RMP programs is really being effectively applied by named participants. Council recommended new funding for all three of the activities proposed, however, because of present RMPS fiscal restrictions the region was granted a reduced award for support of Project #10 - Family Prevention Program on Stroke. The region submitted to the November 1970. Advisory Council an application requesting new funds for support of two new activities. Additional funding was recommended by Council at a reduced level, but because of existing RMPS fiscal restraints no additional funds were awarded. Puerto Rico RMP -7- RM 00065 5/71 PRESENT APPLICATION This is an anniversary application in which the PR/RMP has requested continuation support in 02 operational year for Core and seven ongoing projects, and new funding for a Developmental Component and two new projects. CORE STAFF The Core staff of the PR-RMP has been expanded from 29 to 44 positions with all but one employee at less than 100% time and effort. The organization of the Core staff is shown on Figure 1 and reflects a basic line/staff differentiation. The staff functions are identified as Administration, Biostatistics, Planning and Public Relations. The line functions are Education, Research and Service. The Regional Office covers the three basic subregions of Mayaquez, Ponce and San Juan. The Region indicates that with problems in recruitment it was necessary to adjust the structure in order to carry the program forward. Transfer of personnel from staff to line functions provided temporary refief in the areas of research and services. The region has accomplished this by adding eleven new positions to staff the subregions in Ponce and Mayaquez and hire per- sonnel for the Planning, Research and Evaluation Section of the Central Core office. This was done within the present funding level for Core by utilizing funds available from vacant positions which the region has had difficulty in recruiting. For the next grant period the following Core sections will work in the following activities. “Biostatistics Section (1) Implementation of the proposed Planning, Research and Evaluation. (2) To implement at its maximum capacity the general system designed for the evaluation of the different operational projects. (3) To continue updating the health personnel inventory in terms of the more than 50 occupational categories included in our files. (4) To collaborate with the Research Section in the undertaking of studies channeled towards defining the scope, nature and location of health problems and needs (to continue studies of Puerto Rico as a medical care region). (5) To maintain a close working relationship with, among others, the Comprehensive Health Planning Program and the School of Public Health of the Medical Sciences Campus towards the organization of greatly needed data bank, which could be used by any public or private health agency in the Island. Health Services Section (1) lerminate arrangements for the Neighborhood Health Center of Loiza as soon as possible. (2) Visit the Kaiser - Permanente Group Practice and other similar groups in the U.S. with the purpose of collecting as much data as possible for the establishment of similar groups in P.R. Puerto Rico RMP ~8- RM 00065 5/71 (3) Subsidize a project to be carried out by a competent jegal firm. on the legal aspects of group practice and doctors’ corporation in.P.R. . ‘ (4) Continue evaluation of operational projects. (5) Continue their contribution to development of the Global Health Plan for P.R. by Comprehensive Health Planning. Educational Activities Section (1) The region's planscontemplate the development of a continuing education system which could eventually expand to cover the entire region. The proposed strategy is to create a series of semi-autonomous sub-regional systems in the different heaith regions which could develop educational activities tailored to their own needs. These sub-regional systems would be linked to” the Core staff which would provide supporting services such as professional consultation and technological resources. The ‘recently submitted proposal for training general practitioners in the Western Health Region should allow the PR-RMP to test the feasibility of the overall plan. Development and evaluation of. this proposed project has been given high priority for the calendar year 1971. - (2) Development of new types of sub-~professional health personnel . _is another area of concern for the Education Section. The "Stroke" project should provide valuable experience in this field. Its training program for family health workers was scheduled to begin in January 1971. (3) In the area of public health education it is planned to continue. encouraging citizen participation in their own health affairs. The "Project for Education of Consumers in Health Care Planning" in the Caguas Sub-region will serve as a demonstration area for other groups created under the provisions of title 314-B P.L. 89-749. This project may also serve as a continuing education activity for health educators. The project "“Loiza Neighborhood Health Center" would be the first of its kind in Puerto Rico. It would provide a unique | experience in community health including its educational aspects. Public Relations Section Several projects now in incipient stages will become ma jor centers of activity in coming months. These~ will include, in addition to the development of a ''speech bureau": the assumption of leadership in the creation of a Health Information Council made up of representatives of diverse sectors of the community; publication, in conjunction with the Education Section of PR<-RMP and other health agencies, of a bi-monthly calendar of continuing education activities for distribution to all medical & Puerto Rico RMP -9- RM 00065 5/71 and paramedical personnel on the island; as part of the establish- ment of a PR-RMP Library, the organization of an internal inforsation Center on Regional Medical Programs containing all available non-technical material relating to RMP locally and nationally, for the use of the Core staff, advisory groups and others. Planning Section The Planning Section of the Puerto Rico Regional Medical Program was brought into being on August 3, 1970, when Constantino Aivarez, M.H.Sc.P1.,Ph.D., joined the Core staff, As the Program's Planner, Dr. Alvarez first familiarized himself with the organization and began an evaluation. As objectives for its first few months of operation, the Planning Section identified as objectives the drafting of a Master Plan, and the involvement of Section heads and advisory groups in the planning process and in the formulation of the Master Plan itself, Following his evaluation of the Puerto Rico Regional Medical Program, the Planner presented the First Evaluative Report on the Regional Medical Program from the Planning Viewpoint, Further, he held orientation sessions with the rest of the Core staff wherein he described the planning process and its importance, and outlined the model to be followed in the drawing up of the Master Plan. (Brief description of Master Planning~-Section VI of application) The predominant. activity of the Section was the actual drafting of the Master Plan in coordination with section heads, consultants and task forces. Additionally, the Planner has, on request, provided advice on various planning matters to the Coordinator and the section heads. Chief among the activities of the Planning Section for the coming year is the implementation of the Master Plan. The Planner will also be required to assist the other section heads in the formulation of their own individual long and short term programs, and to help the task forces prepare their guidelines. The two-year program of action for the Planning Section includes a review of indications used in the preparation of the Master Plan and the formulation of new indicators. During the third and fourth years, a revised Master Plan will be developed. Research Section This section became operational on September 1, 1970, with the appointment of Brian F. Mullan, a Health Services Researcher and Institutional Planner. Mr. Mullan, a Ph.D. candidate and full- time employee, holds a joint appointment in the Medical Sciences Puerto Rico RMP -10- RM 00065 5/71 Campus of the University of Puerto Rico which is the parent ; organization of the PR~RMP. In addition to his research role he has also served in the capacity of organizational, analyst and institutional planner. The primary concern of the Section during the period September 70-December 70 was the preparation of the "Outline of Proposed Research" and the "Organizational Analysis" in addition to participation in development of the- Program Master Plan. Beyond the activities mentioned the head of the section partici- pated in the National Conference and Workshop on- Evaluation in September 1970. He also visited other research groups in the U.S. and Puerto Rico for possible collaboration and exchange of ' data. The research proposed in the “Outline” reflects an innovative approach utilizing the entire community as the point of departure. From the socio-cultural setting a health disease profile including characteristics of supplier and consumers is prepared. To this profile existing technologies (available or desired combinations of personnel, facilities, programs, etc.) are applied and the resulting quality distribution and continuity of care are analyzed. Important elements in the evaluation of the system are its capacity to serve the health/disease profile and the effectiveness with which it consumes its resources in reaching specified goals. Obvious implications for policy and priorities are included. Some of the basic recommendations in the Proposed Research were: 1 - A community oriented, systems based, and interdisciplinary, approach to the study of the health referral system towaras national and international comparison. 2 ~ Design of an information system organized around basic files in facilities, personnel; services organization, technology and socio-cultural elements. 3 - Necessity for determining relative capacities of sub-systems (Personnel, Facilities, etc.) and the balanced design of these. 4 - Need to generate profiles of standard units of analysis (Health Center, District Hospital, etc.) for comparison within the public referral system and to contrast public and private performance. 5.- Studies on manpower utilization and system organization were given high priority. 6 - Increased sophistication in data analysis and examination of the reliability of data collection procedures. During the coming year emphasis will be placed on studying the organization of the delivery system and designing the basic information system. Beyond that period the areas of manpower utilization, profiles of standard units will be investigated. © Puerto Rico RMP -11- RM 00065 5/71 . MAYAQUEZ SUBREGION 1. If the proposal for the Creation of an Inter-Agency Center for - Information on Early Detection and Treatment of Cancer in the Western Region already approved, is instituted, the subregion will supervise its implementation and aid in its evaluation. If the proposal for the creation of a Continuing Education Program for General Practitioners in the Western Region is approved and funded, the subregion will work in the planning, implementation, development and evaluation of the Program. The subregion will continue promoting the Regional Medical Program in the Western Region and coordinating activities with all the institutions and agencies in the Region, mostly those dealing with the delivery of health services, ‘Puerto Rico RMP ~12- RM 00065 5/71 M / PUBRTO RICO REGIONAL MEDICAL PROGRA - CORE STAPF - SAN JUAN REGIONAL OFFICE FY LINE y STAEE ORGANIS AT TON . COORDINATOR | | ASSOCTATE COORDINATOR eae _ greene —— ADMINISTRATION - PLANNING BLOSTATTSTICS [ PUBLIC | RE LAT TONS mayacuez «| | _ a PONCE SUB-REGION EDUCA AT TON RESEARCH SERVICE SUB-REGION Puerto Rico RMP s Name Cristino Coldn, M.D. Vacant " Luis Miranda, M.D. Vacant Patrick Crenshaw, M.D. Orlando Nieves Carmen Allende De Rivera Vacant Carmen Lydia Rodriguez Betsy Napoleoni Minerva Virella Olga La Luz Betty M. de Diaz Vacant Vacant Ada M. Pabon Eunice Delucca Dolores del Valle Joe Nazario Vacant Maria L. Vigo armen Segui lberto Cardona, M.D. armen L. Valentin R. Norris Blake Juan E, Perez David Goitia Luis Vallafane Carlos Diaz Mendez . Vacant : Vacant Herman Steidel Mildred Ramirez Jose N. Correa Rosario Flores Jose Aveillez Hector L. Rivera Zoe R. de Cantellops Luz D. Rivera Ines M. Oliver Constantino Alvarez Nilda Figueroa Alba E. Santiago: Brian Mullan, Ph.D. -13- CORE STAFF Job Title or Function Coordinator Assoc. Coordinator Assist. Coord. Education Assist. Coord. Research Assist. Coord. Health Services . Administrator Biostatistician Hospital Administrar Health Educator Tech. Assistant Clerk Steno. Clerk Steno. Clerk Steno. Clerk Steno. Clerk Steno. Clerk Typist Clerk Typist Clerk Typist Messenger Social Scientist Statistician Statistical Clerk Associate Coord. (May) Clerk Steno. (May) Pub. Relations Director Pub. Rel. Technician Illustrator Audiovisual Driver Nursing Coordinator Social Worker Medical Librarian Statistical Clerk Associate Coordinator (Ponce) Clerk Steno (Ponce) Assist. Coord. (May.) Coder Assist. Coord, Coder Research Assistant Planner Research Clerk Steno. Organization Specialist RM 00065 5/71 % Hours Time and Effort 100 1600 100 . 50° 100 100° 100 100 * 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 . 100 100 ‘100 100 100 100 100 100 100 100 100 100 100 100 * 100 100 100 100 100 Puerto Rico RMP -14- RM 00065 5/71 THE REGIONAL ADVISORY GROUP oe mT a The Regional Advisory Group. reports that the PR-RMP has had a consider~_ as able impact: through its operational projects, pilot projects; studies © into the utilization of resources at the level of health centers; studies of continuing education; and through the creation of cooperative arrangements. They indicate that the region has made considerable progress in the development of a Master Plan for the region, which sets the direction and course for the next four years. ; The region identifies in this report the health problems of the region in the RMP areas of concern. They explain the criteria utilized in the establishment of priorities and the problems of greatest urgency. The size of the Regional Advisory Group has been increased to 25 members to include more consumer representation. It has also developed Regional Advisory Group By~Laws which are included in the April 1971 review cycle application. Nominations for membership to the RAG are made through the Program Coordinator and are subject to approval of the Core staff and the RAG. The tenure of office shall be 2 years with a right of succession for one term. Meetings are held quarterly with an annual meeting preceding the anniversary review of the program, The present membership of the RAG includes: , Practicing Physicians Medical Sciences Campus ‘School of Medicine and Medical Center Officials Hospital Administrators Appropriate Medical Societies Voluntary Health Agencies Commonwealth Department of Health Municipal Government \ veterns Administration Department of Education Other Health Professions Prominent Civic Leaders Health Consumers bol Dif Fp em PE ety © Puerto Rico RMP -15- RM 00065 5/71 Executive Committee This Committee is composed of the officers (Chairman, Vice Chairman and Secretary) and four members elected by the Regional Advisory Group. The Executive Committee is authorized to act for the Regional Advisory Group between meetings with actions subject to subsequent approval by the Regional Advisory Group proper. Task Forces The PR-RMP has identified in this application six task forces and has indicated that it is in the process of developing quidelines and operational procedures for all of these groups. Indicated below are the Task Forces and their total membership: Planning 10 Stroke 15 Cancer 10 Continuing Education 11 Diabetes 17 Heart 13 © An organizational chart of the PR-RMP can be seen on Figure 2. DEVELOPMENTAL COMPONENT The region explains that the elements of the Developmental Component have been determined by selection of those items which the program development plan logically suggests and which are, conson nt with the pertinent sections and explicit terms of the Airlie House document of May 1970. The alternatives considered in utilization of the developmental component are as follows: 1. (Disease Oriented) Kidney and Stroke Studies 2. Education-Research Area 3. Application of a Health System Model The region indicates a preference for alternative number three.. A. single committee (tentatively the existing Planning Committee) will constitute the sole review body for the processing of new proposals. To expedite matters the proposal will then proceed directly to the Regional Advisory Group. Administration of the projects would be carried out by the Administrator of the Core staff. The region indicates © that an adequately functioning working group has already demonstrated its capacity to incorporate new projects by a flexible structure which responds on the basis of need. | Puerto Rico RMP . -l6- - RM 00065 5/71 ° - PUERTO RICO REGIONAL MEDICAL PROGRAM GENERAL ORCANEZATIONAL ARRANGEMENT REGIOWAL HEDICAL PROGRAM SERVICE | WASHINGTON, D.C. OTHER REGIONAL poe «= MEDICAL PROGRALIS | “PUERTO RICO | REGIONAL ADVISORY | RECLONAL MEDICAL PROGRAM | PLANNING COMMITTEE Z GROUP © _ ‘CORE STAFF - im | CONSULTANTS. ROJECTS = a“ oO _ TASK FORCES PEDIAYRIC CARDIO- | — HEART VASCULAR STROKE HELB.TOLOCY - en , . CANCER . CHROMIC PULMONARY CONSULTANTS DIABETES DIABETES EDUCATION - 7 RENAL CRNOE2 REGISTRY , : “HYPERTENSION DEMONSTRATION STROKE ARTERTOSCLEROSIS COMMUNITY STROKE CONTINUING EDUCATION | GENERAL ORGA} [ZATION AL ARRAN CRnEeNt Puerto Rico RMP -17- RM 00065 5/71 PROJECT REVIEW PROCESS Following are the procedures utilized by the region in. the review of proposals: 1. Operational grant application is prepared by the applicant. During its preparation, the members of the applicant organi- zation may seek necessary consultation from the core staff. This application is then filed with the Coordinator of the RMP. Applications are registered by Miss Betsy Napoleoni, using @ "Project Proposals Flow and Control Sheet". , 2. The Coordinator refers the application to his staff for analysis and evaluation. 3, The staff will provide follow-up documentation and analysis, with regard to the following criteria. a. That the application proposes to fill a demonstrated , need in the improvement of patient care, giving emphasis to primary care in relation to heart disease, cancer, stroke, and allied illnesses. b. That it demonstrates joint and workable cooperative arrangements in the organization and administration of the existing health services in the Region. c. That it encourages the improvement and growth of the health manpower pool. d. That funds are to support new programs, not existing ones. Emphasis will be given to exploring new systems of care in relation to heart disease, cancer, and stroke patients and other allied illnesses, e.. That the proposal will provide for a phase out period, . presenting adequate and acceptable sources of support at some future time. f, That the project is feasible using the personnel and facilities in existence or available. g. That the application provides for meaningful evaluation of proposed activities. 4. A Committee will be formed of two staff members for the review of each proposal. Suggestions made by this committee will be sent to the RMP Coordinator. 5, The RMP Coordinator and/or representative will meet with representatives of applicant organizations to discuss suggestions of various committees. 6. A Core staff member will assist applicant organizations in making necessary changes suggested by the Core staff Review Committee. The proposal will then be prepared for review by the Task Force covering the area of concern presented in the proposal. Puerto Rico RMP -18- RM 00065 5/71 7. 10. 11. 12, 13. 14. The Task Forces will review each Operational Grant Application | received from the staff, according to criteria determined by that Committee, Presentation of each proposal to the respective Task Force will be made by representatives from - ‘applicant organizations. The Task Force may recommend that proposals be forwarded to the Planning Committee or returned to the Applicant Organi- zation under one of the following conditions: disapproved, or approved subject to modification. In the latter event, the proposal may be resubmitted following incorporation of the recommended changes. , m Tf the Task Force rejects a proposal, it shall clearly state its reasons for doing so. The Coordinator will then forward a letter to Applicant Organization stating the reasons for the rejection. — Once reviewed and approved by the Task Force, proposals will be sent to the Planning Committee. If a proposal is approved by the Planning Committee, it will be sent to Regional Advisory Group. If approved by the Planning Committee subject to modification, it will be sent directly to Regional Advisory Group following revision in accordance with the recommended changes. If the Planning Committee rejects a proposal completely, reasons for the rejection will be clearly stated and a letter will be sent by Coordinator to the Applicant Organization stating the reasons for rejection. Copies of each proposal will be submitted to each member ‘of the Regional Advisory Group, at least two weeks prior to a meeting. However, there will be a committee of the Regional Advis ry Group, composed of two persons, who will be-responsible for the proposals to be discussed. At the time of discussing a proposal at a Regional Advisory Group meeting, representatives of the Applicant Organization will make the presentation. The Regional Advisory Group Committee which has the main responsibility for the discussion of the proposal shall be permitted to question these representatives. If the application is approved with modifications by RAG, it will be referred by the chairman of the RAG to the RMP Coordinator, who,-together with the Applicant and a representative of the Regional Advisory Group, will reconcile the points objected to, after which the proposal will be returned to RAG chairman for final approval. Puerto Rico RMP -19- RM 00065 5/71 15. The Puerto Rico Regional Medical Program Coordinator, acting for the Grantee Institution, the University of Puerto Rico Medical Sciences Campus, will receive all operational grant applications approved by the Regional Advisory Group. ..It- will be his responsibility to determine that each application conforms to RMP policies, and to submit the application to the Regional Medical Program Services, Department of Health, Education, and Welfare. ° PROGRAM EVALUATION The evaluation section of the PR-RMP has established an evaluation protocol for both projects and total program. This protocal is identified in pages 71-74 of the May 1971. continuation application. SUPPLEMENTAL PROJECTS First Year Project #14 - Medical Communication Center in the Southern Request Health District of Puerto Rico (Ponce): $68 ,026 The applicant organization of this proposal is the Southern Distric Medical Society of the Puerto Rico Medical Association. The purpose of this program is continuing education of practicing physicians in this area, The Center itself will be available for physicians on a daily basis so that they can utilize audiovisual equipment and materials. Frequent meetings, short courses, seminars, and related activities are contemplated. In addition, portable equipment will be rotated-probably at weekly intervals through hospitals, health centers and others so that they may avail themselves of the learning material at their convenience. It is indicated that in the future the scope of the program will be expanded to include paramedical personnel. The region indicates that it is likely they will request for a third-year support when they submit their triennial application. Second Year: $68,485 Project #15 - Creation-of a Continuation Education Program First Year for General Practitioners in the Western Health Request Region (Mayaquez): The applicant organizations of this $14,927 proposal are the Western Sub-region of PR-RMP, Western Health Region Health Department and the Western Chapter of the Medical Association. This program proposes to create an educational mechanism to provide continuing medical eduction to the general practitioners in the Health Centers and in private practice in the West Region. The program will concentrate primarily on giving the participants theoretical information and clinical experience in the treatment of cancer, cardiovascular disorders and gastrointestinal disorders. Puerto Rico RMP " -20- “RM 00065 5/71 The course will be of 3 months duration, It will have two sessions per week of two hours duration each. The number of M.D.s to be , *. enrolled per course will be a maximum of 15. The course will be offered three times a year reaching then a total of 45 M.D.s per year. It is indicated that a third year of funding may be requested when the region submits its triennal application. | Second Year: $16,672 RMPS /GRB/3/11/71 © " 2 REVISED-3/10/7: KUCTON, Puerto Rico . CYCLE RM 06065 5/71 LXEANOUT OF REQUEST_ 02 __PERIOD - (Anniversary Review) TEONTINGING | TPREVIGUSLY ! NEW : ‘ACTIVITIES RENEWAL {APPR/UNIUN, |ACTIVITIES | DIRECT INDIRECT + TOTAL 5 { ! : ’ 95 44g | 95,448 | -- 95,448 _! i. | ; | | 316,405! | | 316,405 : 53,154 | 369,559 _| i i i : : i i Disease ! 150,000 _* : | 150,000 } 14,744 | 164,744 | #2 damatology, Cancer : i | : i : : __Chemotherapy & Blood Bank 75,000 _! i 75,000 i; 11,850 | 86,850! “¥3 Chronic Pulmon. Disease ; : i ! i t . i i Center for Children ‘125,000; ; i i; 125,000 | 16,284 : 141,284! #4 Diabetes Mellitus ' Cc to me i : ___Eduzation Program | 64,595 ! ‘ ; .64,595e! 6,963 | 71,558* ; ; t ; #5 Geneee Registry * 25,600 ; ,25,000 ' 7,500 : 32,500! , #7 ICC Tra aining - RH*s & { ; ' : i i Mo's i__ 90,000 } ' 90,000 { 13,645 | 103,645 Fio Comunity Family - : ' i : i 4 i ‘ ____ Stroke Prevention "212,163 i 112,163 | 19,377 $ 131,540 T i i ! #14 Medical Cora. Center | | i 68, 026 1. 68,026 | 4,709 72,735 oe , ' a “| ' 215 General Practitioners CE / 14,927 | 14,927 | 950 5 15,877 | oe — Y 7 : . i : i | Tt | 3 : : ! . i ! ‘ ‘ _. _ 7 ! | : : . : ‘ : ' : 7 ' | ; t - ! ; : i | t end : : 1 ‘ ; i : : — 1 Tora, $958,163 0 | 178,401 =: 1,136,564 1 149,176 | 1,285,740 dWy Od;y O3a9nd “12. 1£/S $9000 Wa TT Tepe == —S erwaas - Thaw } i | aus > - = ~ eee meee r ~ t ee we mye pe nese eee saat aot - + - ‘ Ros AG : a : ACTIVITES ! Dal Lae cen tek weet are ~ la ' ae as ——= eee ee nn eer ee enter nines = me aeenin tea ge sa ame eae mam . . 95,448 | __ 95,448. | ai OoFw ojszang | | . - | i 316,405. 369,559 __ | . t ~ ; 41 | 150,000. _ 164,744 | | - a2 : 75,000 86,850 Fi i " 7” ‘ #3 | : 225,000 141,284 3 | } ; 64,595 *71,518* - 8 fe ee a a lene #5 i | 1 No i 25,000 -\ 32,500 #5 ; : a 2,500 a7 © 90,000 103,445 = “ ' ! : : A : : 07 ; : ; ; 112,163 | 132,540, a - : : a , _ aE As —_ . ' 68,485 | 68,485 | 8,826 . 77,309 136,511, 150, 044% #15 : ; 16,672: 16,672 | 950 17,622 31,599 + -33,499* : a | : Vo 8 . ' 3 i : : g 7 on ; . — — “am ‘ cone i i 2 “ 1 : ‘ ‘ Pon me alia -_— — —— : : ; 1 , io ; 3 : | t . ~ ' ~ ee eee ~~ : : ! . se, ; 85,157. 85,157 | 9,774 = 94,932 ‘Laat, 721 1,380,671 *Budget Estimates for 3rd year to be included in Triennium Review Application Provran Funding: + COMPONENTS BY DISEASE C. ‘SEGORY Approved for Current Year Operating level in Current Year (includes funds carried forward)--<*-7> $ Recommended Commitment for next year---§ EART On-going # Projects 2 total $8 240,000 %.§8 25% Approved/unfunded 0 Dizanoroved 0 TANCER Ca-zoing * Projects 2 jotat $5 100,000 z $s 10 Approved /un funded 4 Leapproved 0 Bb were ee wer ete STROKE On-going 1 * Profects foral $$112,163 %$S °° 12 sroved/unfanded ] approved _O CLDNEY Oa-ypoing + Projects Total $$ % $$ Approved /un funded anreved -0O- Ni oor prerad soe Urae Ammar ermal aie nctneeree es mamdmmamd, * RELATED DISEASES Ca-sotneg + Projects 2 total $3 185,919 | % $S Anproved/un funded 0 Disserroved 0 HULTICATEGOR ICAL - On-eotne # Projects O Total $s 0 % $8 Approved/unfunded Q Di sapproved 1 GEUERAL Cn-poing # Projects 1 (Core) Total $$ 320,081 2 $3 33 ppraved/unfunded 1 Pisapproved 0 -23- RM 00065 5/71. Region PUERTO RICQ we eeeeeeee-nee$ 1,246 250 ‘ 958,163 958,163 PROPOSED COMPONENTS Curcent Operational Year: 6/70-5/71 Ficst, Scheduled AR application Feb. 71 April 1971 Committee Region's optional plans: None COMPONENTS BY TYPE OF ACTIVIT TRAINING AND EDUCATION On-going oO Project #14 - Medical Communication Center ; $68 ,026 + # Projects 3 Total $$ 225,919. % $8 24 . | Approved/unfunded 1 - Disapproved IT $ DEMONSTRATION OF PATLENT CARE * On-going # Projects 4 Project #15 -- C.E. Program for General Practitioners $14,927 _ Total $8 412,163 % $S Approved/unfunded & Disapproved Q RESEARCH & DEVELOPMENT On-going # Projects Total $8 - % $s Approved /unfunded Disapproved PADMENISTRATION & PLANNING On-eoing , u 4 projects 1 (core) Total $8 320,081 % $8 33 Approved/unfunded = 1 Di sapproved -24-— DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Date; March 11, 1971 Reply to : - me oo $ Altn of: ° a . - Subject: Staff Review of Non-Competing Continuation Application from the Puerto Rico” - Repional Medical Program for May 1971 Review Cycle 5 G03 RM 00065 To: oO , pe . Lo Acting Director Regional Medical Programs Service AO” 2 THROUGH: Chairman of the Month — 7 _ Chief, Grants Review Bade) wen f Chief, Grants Management Branch Lege . se : / a / ; : Mpc nGh” Acting Chief, Regional Development pct a Recommendation: Staff recommends continued support of Core and seven oncoine projects at the committed level of $958,163 for the rezions second operational year. - Based on the recent Weduction, however, of the Commit- ment by the RMPS of $81,443 the region's commitment for fiscal year "1971" is $876,720. , Core $316,405 Operational Projects (7) 641,758 Staff Recommendation 958,163 Deduction by RMPS “ 81,443 Basis for award . 876,720 Staff review of the continuation application concentrated on overall program issues. Major issues discussed by staff were: Regional Advisory Group - Four new members have been.added to. the Regional Advisory Group, all representative of the health consumer. They are: an industrialist from Ponce, an insurance executive, a banking executive and an attorney. Staff believes this increase in consumer representation will strengthen the RAG, however, consumers to represent the lower economic population and the Model Cities Programs are not represented. The Northern and Southern areas of the region are well represented on the RAG, but there. is no representation from the Western and Eastern areas of the region. . The RAG report is general and non-specitic. It gives the impression that ~25- Page 2 - Dr. Margulies the RAG has not assumed the leadership role for the PR/RMP. With the caliber of persons on the RAG, this group, it they assumed strong leader- ship ot the program, could have a positive rather than a passive in- fluence in the health care system of Puerto Rico. Staff believes that if the PR/RMP is to effectively serve as a catalyst in bringing the two major providers of health services in Puerto Rico - Private and government medicine - to jointly confront the major health problems ot the region, it will have to do so through the leadership and active parti- cipation of the RAG. Staff sugpest that methods of operation, responsibilities assumed, and utilization of manpower of this group should be a topic of dis- cussion in future site visits. rn, COKE The Core statt has been increased from 29 to 44 positions. This increase in staff is primarily for the acquisition of personnel for the subregions ot Ponce and Mayaquez. It also includes personnel from the recently organized Planning, Research and Evaluation Section of the central core office. No additional funds are requested for the new positions. They are to be funded from within the level of funding for Core by utilizing available funds from vacant positions. , The utilization of these core funds to support these new positions may presently restrict the region from filling the positions of social worker, hospital administrator and registered nurse now being recruited. It will however, allow the region:to establish a subregion in Ponce and Mayaquez: and to strengthen its planning and evaluation for central core staft which are priority items. TASK FORCES The membership on the task forces primarily consists ot physicians, with little if any representation of allied health personnel. Staff believes that allied health personnel can contribute and should have an opportunity to participate in the task forces. It appears to staff that there is little organized interrelationship between the task forces, nor an established operating procedure which would stimulate an integrated program effort between task torces, RAG, Planning Committee and Core. It is suggested that core staff input be built into the meetings of these groups to keep them abreast of total program activities and to encourage further input by these groups into the PR/RMP. The general impression of staff is that the task forces have been project - oriented and have not assumed the responsibility for developing a Regional -26- Page 3 - Dr. Margulies plan of action for each of the categorical areas they represent. This lack of regional planning is apparent in the projects which have been submitted. — There is no mention of how each activity interrelates. with others in the... same categorical area. There is also little mention of how each activity. fits into a regional plan. Staff suggests that in future site visits. these concerns of staff should be included as a topic for discussion. ) . OPERATIONAL PROJECTS The seven operational projects have been funded for less than a one year period. Taking this into consideration, staff concurred. that they have made satisfactory progress. When the region is site visited,*Project #10 - Community Family Prevention Program on Stroke and Its Incapacitating Complications ~ Should be evaluated to see what progress has been made. This is in line with previous Council reconmendations. The region reported some difficulty locating space for this project #10 at the Guaynabo Health Center _and also with the recruitment of staff. They have however, indicated that these problems are being resolved. — 7 GENERAL Staff believes that cooperative relationships have been established and the regionalization process is developing. The Region has defined as major problems within the government health system ‘ poor organization, utilization and administration of health resources. It. would be interesting in a future site visit to see what the PR/RMP is doing to assist government medicine in resolving these problems. : oo The following staft members attended the meeting on March 5, 1971 Ismael B. Morales, Grants Review Branch, Chairman Loretta W. Brown, Otfice of Program Planning and Evaluation Lawrence H, Pullen, Grants Management Branch Frank S. Nash, Regional Development Branch Elsa J. Nelson, Continuing Education and Training Branch Jessie F. Salazar, Grants Review Branch Mike Posta, Regional Development Branch Cleveland R. Chambliss, Oftice of Organizational Liaison ’ J tlle Fiero Ismael B. Morales Public Health Advisor Grants Review Branch ep ved: . dna Ue SS if if 2f Reting Director, RuMeS Date A aad \ *implicit in the original recommendation of approval, was the interest -27- Page 4 - Dr. Margulies © in seeing this project develop into a pilot training center and stroke resource for all of Puerto Rico. The site visit team felt, however, that this would not. take place unless follow-up consultation was provided once the project began. Since it is too soon for a program site visit, it-~might be well to have a special consultant visit the project some time soon. pS bebed “Sarah J. Silsbee Chief, Grants Review Branch ' a (A Privileged Communication) -- . . SUMMARY OF REVIEW AND CONCLUSION OF °. APRIL 1971 REVIEW COMMITTEE PUERTO RICO REGIONAL MEDICAL PROGRAM RM 00065 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL - . RECOMMENDATION: Committee recommends a funding level of $973,990 direct cost for support of Core, seven operational projects and two new projects. The request for a developmental component award was disapproved. Taking into consideration the recent administrative action by RMPS which reduced the Region's fiscal year "1971" commitment by $114,980, the operating level of funding will -be $858,110. DIRECT COST ONLY Year . Request Recommendation 02 $1,136,564 $973,090 03 85,157 $ 16,672 (Proj. #15) Total $1,221,721 . $989,762 “Includes funds committed for core and seven on-going projects; actual © funds to be awarded will be reduced by $114,980 thru administrative action. GRITIQUE: Committee believes that although the seven on-going =. projects have been cperational for less than one year ~ most of them have managed to give the Puerto Rico RMP visibility and outreach. Concerns were expressed over the cancer registry project which has had a chronic problem with follow-up activities. The region may want to evaluate this activity in relation to other priority activities which they may be able to fund, Committee suggests,that as recommended by the last site visit team,a special consultant visit should be scheduled for Project #10 - Community Family Prevention Program on Stroke and its Incapacitating Complications. Committee was encouraged by the increased representation of consumers on the RAG, however, consumers to represent the lower economic population and the Model Cities Programs are not included, They also noted that although the Northern and Southern areas of the Region are well represented on the RAG there is no representation from the Western and Eastern areas. In addition, the membership on the RAG primarily consists of top echelon personnel with no representation from the allied health professions. Committee believes that allied health personnel need to be represented on the RAG and other committees of the PRRMP. Overall it does not appear © that the RAG has assumed the leadership role for the PRRMP. ~ PUERTO RICO RMP ~2- : RM 00065 5/71 There seems to be a tendency in the PRRMP to become institutionalized away from the University, Department of Health and other major health institutions. Committee believes the PRRMP can be more effective if they assume the role of catalyst and devote their efforts in stimulating cooperative arrangements in health planning and program development between the major providers of health services in the region. . Committee expressed some concerns about Core not having adequate representation from the nursing and social services professions which could enhance their outreach into the community. t Committee believes that the new projects submitted in this application do not address the real needs of the region. They focus on continuing education for physicians in the health centers and .overlook the “private practitioners in the community. Committee believes that the primary goals of these projects should be to stimulate a cooperative relationship between private and government medicine so that they can cooperatively meet the health needs of their community. This is especially true now that PL 56 has been passed by the legislature, which permits payment of services of private patients in government hospitaits and for indigent patients in private hospitals. In addition, Committee believes that there are good: opportunities now in Ponce (Southern Region) and in Mayaquez (Western Region) for the PRRMP to have an impact because both areas are developing medical centers. By getting in on the ground floor, the PRRMP may be able to influence the development of cooperative arrangements and a regionalization process that would involve both government and private medicine in the areas. Particular emphasis was placed (on Ponce) by Committee because it has progressed much faster than Mayaquez. Committee did not recommend additional funds for Project #14, but did encourage its development and support from local resources. They recommend that this activity be coordinated with the already existing continuing education program established in Ponce by Dr. Hector Rodriquez in coronary care. For Project #15, Committee recommended an award of $14,927 with the recommendation that the program be expanded to include the private sector°of medicine and allied health personnel. This project is viewed. as the creation of a continuating education program for the Mayaquez Medical Center area, RMPS /GRB/4/26/71 nee REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) SOUTH CAROLINA REGIONAL MEDICAL PROGRAM RM 35-04 5/71 Medical University of South Carolina April 1971 Review Committee 80 Barre Street Charleston, South Carolina 29401 Program Coordinator: Vince Moseley, M.D. This region is currently funded at $1,292,791 (direct costs) for its third operational year (which is an 1l-month period) ending June 30, 1971. Core is supported at $456,498 (d.c.) and 16 projects at $836,293 (d.c.). The Region has submitted a triennium application that proposes: I - A Developmental Component II - The continuation of Core and three ongoing activities (#5A, #29, #31). III - The activation of 1 Council approved but unfunded activity (#22) i IV - The renewal of 1 activity (#13R) V - The implementation of 20 new activities (#39-#58) VI ~ The termination of 12 activities ' The region requests $2,991,048 (d.c.) for its fourth year of operation, $2,727,436 (d.c.) for the fifth year and $2,993,955 (d.c.) for its sixth year. A breakout chart identifying the components for each ' of the three years is presented on pages 3-5 of this summary. Four of the proposed new activities have previous review histories. | These are projects #47,54,56 and 58. This point will be elaborated on later in the body of this summary. A site visit is planned for this Region. Staff has conducted a preliminary review of the application, which as a result of new policies is quite superficial and leaves many questions unanswered, and has identified the following as issues which need further clarification at the time of the site visit. These are covered in greater detail in the attachment to this summary. 1. The functioning of the large 70—member RAG. 2. The effect of the RAG's composition, with the preponderance of the Medical Society and hospital interests, on the program © priorities and policies. 3. The effect of the various committeeg' composition on program priorities and policies. 4. The specific functions of Core Staff members and their relationships to the community, Local Advisory Committees, RAG and each other 5. The.program objectives,the bases on which they were established, ‘the time frame for achievement and the method of evaluation. 6. Clarification of the review process. 7. The evaluation processes, both project and program. South Carolina Regional Medical Program -2- RM 35-04 5/71 FUNDING HISTORY Planning Stage Grant Year Period Funded (D.C.) 01. 1/1/67-12/31/67 $100,673 02 1/1/68-12/ 31/68 $316,675 03 1/1/69-7/31/70 $420,000 Operational Program Grant Year Period Funded (D.C.) Future Commitment (D.C. OL 8/1/68-7/31/69 $826,435 1/ = ~ 02 8/1/69-7/31/70 $1,177,626 2/0 ttm 03 8/1/70-6/30/71 $1,292,791 3/ . ——oo 04 . 7/1/71-6/30/72 s---- $563,477 4/ ; 05 * 7/1/72-6/30/73 wee $202,255 (5 mos.)5/ *The indirect cost rate for the Region for the current year is approxi~ 24.1% and represents $312,016. 1/ (Projects only, Core still under planning) 2/ (Core only partially supported $202,256 (d.c.) by this award) 3/ (This represents total program support, both Core & 16 projects for 11 months) 4/ Core and Project #29 5/ Core only SOUTH CAROLINA __ _RM 00035 5/71. j 5 5 i OF (Triennium) ENTIFECATION OF CONTINUING | PREVIOUSLY NEW MPONENT ACTIVITIES | EWAL APPR /UNFUND, [ACTIVITIES DIRECT INDIRECT TOTAL RE $615,490 $ 615,490! $207,686 |$ 823,176 A - CCU Nurse Training 56,877 56,877| 16,169 73,046 3R - Mid. G.I. 845,808 | 45,808, _ 8,332 | 54,140 2.- MUS Heart Clinic $67,816 67,816] 16,023 83, 839 9 - Pediatric Heart 78,065 ot ve eee ie ee 78,065) 23,127 | 301,192 tL - Demonstration Project- : Continuing Education 62.200. econo 62,700} 17,163 | 79, 863. 38 - Comprehensive CCU $ 106,900 106,900 36,750 143,650 39 - Statewide Heart 59,718 59,718 12,194 | 71,912 40 - Stroke Nurse Training 62,154 62,154 12,544 74,698 i] ~ Midland Stroke 148,928 148,928 | 30,712 179,640 }2 - Heart Implementation 99,626 99,626 17,816 117,442 13 - Hypertension 40,564 40,564 | 10,633 51,197 14 - Statewide Cancer Clinic 49,908 49,908 , 9,440 59,348 ‘5 - Nuclear Medicine 68,785 68,785 | 68, 785 16 - Hematologic Malignanciés 81,913 81,913 19,600 _ 101,513 (7_= Oral Cancer 30,271 30,271 | 3,308 _ 33,579 _ 8 - Gynecologic/ Radiother 240,165 240,165 | 55,272 295 ,437 19 - Lab Training 32,470 32,470 4,401 36,871 10 - Mid, Education 129,118 129,118 23,770 152,888 1} + Continuing Education Health Personnel 252,739 252,739 30,723 283,462 2 = Health Manpower 68,115 68,115 4,303 72,418 (3. = Information Network 71,587 71,587 | 14,112 85,699 4 - Planned Discharge 50, 800 50,800 . 50,800 ‘5 = Hemodialysis 65,194 65,194 | 21,511 86,705 6 - Comprehensive Respiratory | Disease Training Prog, |! 179,487 179,487 | 27,685 207,172 ‘7 = Continuing Medical ' Education 100, 850 100,850 | 24,107 124,957 'VELOPMENTAL COMPONENT 125,000 125,000 | 125,000 TOTAL $813,132 $45, 808 $67,816 {$2,064,292 $2,901, O47 38 $3,638,429 veYGiy KM UUUSD d/ 71 BREAK TUY GF REQUEST _ 05 PEKLOD (Triennium) ENTIFICATION OF [CONTINUING | (PREVIOUSLY | NEW ; MPONEST * |ACTIVITIES ‘RENEWAL ‘-APPR/UNFUN. ‘ACTIVITIES | DERECT 'TNDIRECT 3! TOTAL i : i . , : . ! . : CORE = ! $650,035 | i$ 650,035 - $218,069 !$ 868.304 fo #54 {| . 58,845! ‘a 58,845: 16,978 | 75,823 ; #13R : i : : ; -- : #22 : 1 $52,867 : 52,867: 16,824 | 69,691 : #29 : ! i ! ! j { won { #31 ; : i eee #58 ' $115,645 | 115,645" 38,588 | 154,233 #39 | 68,500 | 68,500 14,083 ° 82,583 #40 : : 61,262 | =—61,262 | 13,139 : 74,401 i F41 ; ; __ 148,928 | 148,928, 30,712: 179,640 #42 t P i__117,208 ' 117,208 «18,761 - 135,969 pe #43 : 41,793. | 41,793 11,165 : 52,958 Fad 5; 50,032: 50,032. 10,327. : 60,359 FL5 r " i 60,6049 60,649 --- t= 60, 649 ; 46 : a ' 84,228 84,228 24,696 : 108,924 . 47 ~ _— 33,905: 33,905 3,638 © 37,543 E48 ; "201,633 | 201,633. 63,916 265,549 9 - 25,094.” 25,094, 4,535 1 29,629 '50 S| ws \ ~ #29- Children Heart Disease (Med. U. )- ES PH ensraun \ oo Onmes ree \ #40-Stroke Nursing (Med. U.) ante / A “Nor wits IG Y #43-Diagnostic & Therapeutic AIKEN A onacereune@ Nd YS foe Hypertension (Med. U.) ; L ye ORANCEDURG ~ p “LL econo fe #46-Hemotologic Malignancies Ed. 740) | > aw et BERKELET Ke and Services (Med. U.) , DARNWELL | mie. A. @sr crorce 2 Ouewers Comes UT Xs5 #48-Gynecological Radiotherapy (Med.U) . a. : FN ogrengortis, f #56-Respiratory Disease Trng. (Med. U.) “ DALE A » 2, f\ #53-Information Network (Med. U.) ~ \ Ss 4 #39-Heart Clinic Ed. (Board Health) \ #42-Implementation of Heart & Stroke . (Heart Association) ‘#45-Cont. Ed. in Nuclear Med. (Self Mem. Hosp.-Greenwood) #49-State-wide Laboratory Trng. (Board of Hlth. } #52-Health Manpower (Hosp. Assoc.) 22-Dem, Serv. & Rd. Heart Clinic (Med. U.) #58-Coronary Care Coastal Hosp. (Med. U.) #47-Complications of Radiotherapy to Head & Neck (Med. U.) #55-Hemodiolysis C.E. (Med. U.) #51-C.E. for Heart Profes ae if mameTon » \ © i CHARLESTON oe . C9) \ LORS , oy (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE SOUTH CAROLINA REGIONAL MEDICAL PROGRAM RM 00035-04 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATIONS: Committee recommended that the Region be awarded $1,5 million dollars (direct costs) for each of three years including developmental component funding. The Ad Hoc Renal Disease Panel recommended Project #55 ~ Chronic Renal Disease Education and Service. be. deferred for a site visit. RECOMMENDED FUNDING REQUEST (Direct Costs) (Direct Costs) Fourth Fifth Sixth Each of Three Year Year Year Years CORE $ 615,490 § 650,035 $§ 679,538 ~ «§..500, 000 PROJECTS 2,250,558 1,927,401 -2,114,417 900,000 DEVELOPMENTAL 125,000 150,000 200,000 100,000 TOTAL $2,991, 048° $2,727,436 $2,993,955 $1,500,000 Note: Support of Project #52 - Health Manpower is precluded by RMPS policy which states that RMP grant funds are not to be used for direct’ operational grant support of Health Careers Recruitment Projects. CRITIQUE: Funding Recommends tion - is basically consistent with that of the site visitors, However, while the visitors had __. recommended $1,127,041 of “project. support for each of three years, Committee believed the project level should be reduced to $900,000 which provides for a more modest growth over the current level of support. Also taken into consideration was the fact’ that a number of projects. are requesting | large equipment and personnel items which are inappropriate at this time when RMP funds are extremely limited, Project #5A - Coronary Care Nurse Trainine at the Medical University was cited in particular as requesting excessive personnel who, in fact, would appear to be providing patient services. Program Observations: Committee concurred with the site visitors report which concluded that while the Region has not demonstrated outstanding maturity or quality, it has made substantial progress during its first three years of operation, Given the limitations of categorical disease and continuing education under which the Region initiated its first three-year operational plan, the limited resources _ SOUTH CAROLINA RHP de RM 00035 of the Region, and the skepticism with which many health providers viewed RMP, the Region appears to have been moderately successful in focusing its projects on some of the major problems of South Carolina. It has concentrated through continuing education programs, some involving state-aid clinics, to upgrade the knowledge of the rural physicians who in most instances have not kept current with modern procedures related to heart, stroke and cancer. In addition through the corondry care training projects, the stroke and cancer projects, SCRMP has succeeded in improving facilities and services in rural communities, most of which are medically deprived. The activities promoted by SCRMP have also served to remove much of the skepticism many of the §,C. physicians harbored about RMP and it appears SCRMP through all aspects of its program has succeeded to a large degree to have won the confidence of the various health interests of the medical community. The Medical University which prior to SCRHP was a classic example of an "ivory tower" is new extending itself through many of the projects into the hinterland, Much of the success of the program appeare attributable to the leadership of past and present Program Directors, capable Core Staff (particularly the three associate coordinators), active RAG Chairmen and the interest and dedication of the RAG membership. ey ire eee ee ew ee ee eee ee eee aa The Reviewers noted that theeprogram as designed for the next three years remains highly categorical and will be implemented primarily through traditional continuing education activities, However, they reasoned that the Region has generated a degree of momentum in the direction that can not be abruptly changed and that at the time this application was being drafted, the new and broadening philesophies of RMP had not yet emerged, While Committee members were for the meat part favorably impressed with the South Carolina RMP, they agreed with the site visitors that the following aspects of the program are areas of needed strength. They also felt that while these observations were conveyed to the Region at the time of the visit, they should be re-emphasized and RMP staff should effer assistance and monitor progress. 1. The program remains basically categorical and educational in nature, thereby disqualifying some of the more serious disease problems of the Region and limiting the types of imaginative projects generated for their solution, ° 2. The composition of the RAG is unbalanced and heavily in favor of the M.D.s and Medical Society interests. Aliso, there is under-representation of allied health interests and the Palmetto Medical Soctety. SOUTH CAROLINA RMP / 23e RM 00035 3, While the Region's overall goals and objectives are more specific than most, there is a need for them to be identified in more specific and measurable terms or to establish more specific, sub-objectives. Also, they should be more closely related to “assessed needs." . 4. Core Staff has functioned to date more as a catalyst to persons who have had projects they wished to have funded, rather then as a stimulator of projects designed to meet specific objectives. 5. While the SCRMP has taken positive steps to improve project. —_ evaluation, program evaluation needs additional strengthening beginning _ with measurable objectives, 6, Although rapport has been established with the O£0, Model Cities, and Appalachia Agencies, there is a need for closer vorking relationships and coordinated planning. Project #55 ~ Chronic Renal Disease Education and Service Program ~ did not receive a ‘technical review by Committee, but rather vas deferred for such a review to the Ad Hoc Renal Disease Panel which met the following day. While the Panel felt the Region had done yeoman service in developing needed renal services with small financial assistance, ic believed finel action should be deferred pending a site visit to provide assistance in reduction of certain aspects of the program to prevent proliferation. It was also belived certain budget items will need to be redirected, but will not exceed the amount of the original requests. Note: (Staff -is concerned that this recommendation for deferred action creates a problem in thac Project #55 is an extension and expansion of ongoing Project #18 and such action will interupt the continuity and transition of the program.) GRB/RMPS /4/23/71 Date: Reply to Alla of: Subject: To: . DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE - FUSLIC HEALTH SERVICE — HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION March 23, 1971 y Quick Report on South Carolina Site Visit ~ March 16-17, 1971 (Charleston) birector Regional Medical Programs Service A ft Through: Acting Deputy Director “hae - Regional Medical Programs Service. The site visit team consisted of: Edmund Lewis, M.D. (Chairman) National Review Committee Bruce Everist, M.D. National Advisory Council William Stoneman, M.D. Program Coordinator - Bi-State RMP Russell Lewis, M.D. = Practicing Physician - Marshfield Clinic, Wisconsin RMPS STAFF: Veronica Conley, Ph.D. - Continuing Education Lyman Van Nostrand ~ Program Planning and Evaluation Frank Nash - Regional Development Branch _ Ted Griffith - Regional Office Representative William Reist - Grants Review Branch Representatives of the Region included past and present RAG chairmen, a broad spectrum of RAG members, the Program Coordinator and most of professional Core Staff, including field representatives. It was the feeling of the site visitors that this Region has. made substantial progress during its first three years of operation. Given the limitations of categorical diseases and continuing education under which the Region initiated its first three~year operational plan, it appears to have worked within its somewhat broadly stated objectives, to focus its projects on some of the major problems of the Region. It has concentrated through continuing education programs, some involving state-aid clinics, to upgrade the knowledge of the rural physician who in most instances is serving large numbers of relatively poor. patients but has not kept current with modern medical procedures related to heart, stroke and cancer. Director RMPS -. ge2 - ca In addition through the coronary care training projects, the stroke and cancer projects, SCRMP has succeeded in improving facilities and services in the rural communities of which most are medically deprived areas. The activities promoted by SCRMP have also served to remove much of the skepticism many of the S.C. physicians harbored about RMP and it appears SCRMP through all aspects of its program has succeeded to a large degree to have won the confidence of the various health interests of the medical community. The Medical University which prior to SCRMP was a classic example of an "ivory tower" is now extending itself through many of the projects into the hinterland. Much of the success of the program appears attributable to the leadership of past and present Program Directors, capable Core Staff, progressive RAG chairmen and the interest and dedication of the RAG membership. All are strongly motivated and appear to be contributing to the total strength of the program. While the visitors were favorably impressed with the direction and success of the program during the initial three years of operation, they identified the following aspects of the program as areas of needed strength. 1. The program remains basically categorical and educational in nature, thereby disqualifying some of the more serious disease problems of the Region and limiting the types of imaginative projects generated for their solution. 2. The composition of the RAG is unbalanced and heavily in. favor of the M.D.s and Medical Society interests. Also, there is under-representation of allied health interests. 3. While the Region's overall goals and objectives are more specific than most, there is a need for them to be identified in more specific and measurable terms or to establish more specific sub-objectives. Also, they should be more closely related to assessed needs. . 4.. Core Staff has functioned to date as a catalyst to persons who have had projects they wished to have funded, not as a stimulator of projects designed to meet specific objectives. 5. While the SCRMP has taken positive steps to improve project evaluation, program evaluation needs additional strengthening. beginning with measurable objectives. 6. Although rapport has been established with the OEO, Model Cities, and Appalachia Agencies, there is a need for closer working relationships and coordinated planning. a * © Director RMPS - Page 3 _ RECOMMENDATION: 1. Approval of Core at: . $500,000 2. Approval of project support at: _ $1,127,041 3. Approval of developmental ‘component at: $100,000 Total 1,727,041 a © LEE William S. Reist Public Health Advisor Grants Review Branch (A Privileged Communication) RM 00001 SITE VISIT REPORT SOUTH CAROLINA REGIONAL MEDICAL PROGRAM March 15-17, 1971 (Charleston, South Carolina) SITE VISITORS Edmund J. Lewis, M.D., RMPS (Review Committee), Site Visit Chairman Bruce W. Everist, M.D. (National Advisory Council) Russell Lewis, M.D. (Practicing Phys) Marshfield, Wisconsin William Stoneman, III, M.D. (Program Coordinator) Bi-State RMP Veronica Conley, Ph.D., Continuing Education Branch Lyman Van Nostrand, Program Planning and Evaluation Branch William Reist, Grants Review Branch . Theoda Griffith, Regional Representative, Region IV Frank Nash, Regional Development Branch SCRMP PARTICIPANTS (In Alphabetical Order) Dr. E. Kenneth Aycock, State Health Officer, S.C. State Board of Health, Columbia Dr. Waddy G. Baroody, Assistant Coordinator for Regions VII and VIII, and a Practicing Physician, Internist, from Florence Dr. John P. Booker, President-Elect of the 5.C. Medical Association, and a Practicing Physician from Walhalla Mr. C.W. ("Pete") Bowman, Associate Coordinator, SCRMP Section on Medical Districts Programs Pianning Dr. Rembert 0. Burgess, Chairman, Heart Disease and Stroke Committee of the RAG, a practicing physician, Internal Medicine and Cardiology, Spartanburg Dr. James W. Colbert, Jr., Vice-President for Academic Affairs, Medical University of S. C., Chairman, Regional Advisory Group Mr. J. Walker Coleman III, Director of Program Liaison, Planning and Evaluation Section, SCRMP Dr. G. Preston Cone, Representative of the Medical Districts Committee, a Practicing Physician from Orangeburg Mr. James M. Daniel, Assistant Coordinator for Regional Development, Regions I¥,-V and VI Columbia SCRMP Staff member , Mr. Stephen P. Dittmann, Chairman of the Dept. of Audiovisual Resources of the Medical University of 8.C. Mr. James Dorn, Assistant for Educational Communications, Section on Continuing Education, SCRMP Staff Mr. Fred Ellison, Administrator, York General Hospital, Rock Hill, S.C. Mrs. Esther Fields, Member at Large on the Regional Advisory Group, from Columbia, a Consumer Mr. William B. Finlayson, Co-Chairman of the Regional Advisory Group; Administrator of the Conway Hospital, Conway, S.C. and Board Member of the S.C. Hospital Association Mr. Luther Haynie, former member of the Regional Advisory Group, member, S.C. Chapter, The American Cancer Society, of. Charleston Mr. Robert A. Johnson, Executive Director, Appalachian Regional Health Policy and Planning Council, from Greenville SCRMP Site Visit Report -2- Dr. H. Parker Jones, Representative of the Medical Districts Committee, a practicing physician, Charleston Dr. M. Tucker Laffitte, Jr., Chairman of the Cancer Committee, a prac- ticing physician, surgeon, from Columbia Mr. Henry M. Lee, Chairman, By-Laws and Nominations Committee of the Regional Advisory Group, Board Member of the S.C. Heart Assn, a Businessman of Greenville Miss Anne Liss, R.N., Member, Education Committee of the RAG, Registered Nurse, of Columbia Dr. William C. Marett, Director, Div. of Chronic Diseases of the State Board of Health, Columbia : Mr. Roger H. McCants, Program Representative, SCRMP Dr. William Mellen McCord, President, Medical University of S.C., the Immediate Past Chairman of the Regional Advisory Group - 1966 to 1970 Dr. William C. McLain, Jr., Associate Coordinator, Section on Continuing Education, SCRMP Mr. J. Albert McNab, President-Elect of the $.C. Hospital Association, and Administrator, Hampton General Hospital, Varnville, S.C. Mr. M. L. Meadors, Executive Director of the S.C. Medical Association and member of the Regional Advisory Group, Florence Mr. Marvin H. Miller, Executive Director of the S.C. Heart Association, from Columbia Dr. Vince Moseley ~- SCRMP Program Coordinator Mr. D. Kirk Oglesby, President, S.C. Hospital Association, Administrator, Anderson Memorial Hospital, from Anderson, a member of the Regional Advisory Group Dr. Kenneth Owens, Representative of the Medical Districts Committee and the Education Committee of the RAG, a Practicing Physician, Aiken Dr. Loren F. Parmley, Director of Medical Education, Spartanburg General Hospital, Spartanburg . Mr. Marvin J. Poliquin, Program Representative on the SCRMP Staff Mr. Timothy A.L. Prynne, Assistant for Audiovisual Services and Educational Aids, of the Section on Continuing Education, SCRMP Mr. Gene Shaw, Administrator for Program Analysis on the SCRMP Staff Dr. Charles P. Summerall III, Associate Coordinator for Heart Disease and Stroke, SCRMP Staff Mr. Howard Surface, Program Representative, SCRMP Staff Mr. $.J. Ulmer, Director, Office of Comprehensive Health Planning, State Board of Health, Columbia Dr. Blanche Urey, Consultant for Nursing and Allied Health Education, SCRMP Staff, faculty member of the College of Nursing, Medical University of S.C. Dr. Keene Wallace, Acting Coordinator for Cancer and Nuclear Medicine, DCRMP Staff, Head of Dept. of Radiation Therapy, Medical University of S.C. Mr. William J. Warlick, Executive Associate Coordinator, SCRMP Staff Dr. C. Tucker Weston, Chairman, Medical Districts Committee of the RAG, a Practicing Physician, Orthopedic Surgery, Columbia “rs. Catherine Wheeler, member at large of the RAG, of Columbia SCRMP Site Visit Report a Mr. Norris Whitlock, Director for Epidemiological Studies, SCRMP Staff Dr. Louis Wright, Jr., Vice-Chairman of the Regional Advisory Group, Practicing Physician, a Pathologist, the McLeod Infirmary, Florence, South Carolina Mr. Charles Wyrosdick, Director of Communications, SCRMP Staff Mr. William L. Yates, Executive Director of the S.C. Hospital Association, from Columbia, member of RAG Mr. Robert Youngerman, Inter-Regional Representative of the RMPS, Atlanta, Ga. BACKGROUND: The SCRMP is in its 03 operational year (8/1/70-6/30/70). It was originally awarded $1,292, 791 ‘(d.c.) of which $456,489 was for Core support and $836,293 supported 16 projects. As a- result of recent cutbacks on all Regions, SCRMP's support for the current year has been reduced to $1,162,108. Adjusted budgets have not as yet been received by RMPS. For its 04 year the Region has submitted a Triennium Application that proposes: ’ I. A Developmental Component II. The Continuation of Core and Three Ongoing Activities , . (#54, #29, #31). , III. The Activation of 1 Council Approved but Unfunded Activity (#22) IV. The Renewal of 1 Activity (#13 R) V. The Implementation of 20 New activities (#39-#58) VI. The Termination of 12 Activities The Region requests $2,991,048 (d.c.) for its fourth year of operation, $2,727,436 (d.c.) for the fifth year and $2,993, 955 (d.c.) for its sixth year. Staff. conducted a preliminary review of the application and. identified the following as issues which needed further clarification at the time of the site visit. 1. The functioning of the large 70-member RAG, 2. The effect of the RAG's composition, with the preponderance of Medical Society and hospital interests, on the program priorities and policies. 3. The effect of the various committees’ composition on program priorities and policies. 4. The specific functions of Core Staff members and their relationships to the,conmunity, Local Advisory Committees, RAG and each other. Po 5. The program objectives, the bases on which they were established, _ the time frame for achievement and the method of evaluation. 6. Clarification of the review process. 7. he evaluation processes, both project and program. Site Visit Report Of The South Carolina Regional Medical Program March 16-17, 1971 AGENDA: By prior agreement the site visitors and SCRMP representatives met in plenary session the morning of the first day, then split into three groups based on the Region's major program sections: 9) Heart Disease, Stroke and Related Diseases, 2) Cancer and 3) Continuing ‘Education. A plenary session was held the morning of the second day followed by a feedback session with the Region and an Executive Session. OVERALL OBSERVATION: It was the feeling of the site visitors that this Region, while it has not demonstrated outstanding maturity or quality, has made substantial progress during its first three years of operation. Given the limitations of categorical diseases and traditional continuing education activities under which the first three-year operational plan was designed and initiated, the Region appears to have established a program, within its broadly stated objectives, focusing on some of the major problems of South Carolina. It has concentrated through continuing education activities to upgrade the knowledge of the rural physicians who in most instances have not kept current with modern medical procedures related to heart, cancer and stroke and who are treating a large number of disadvantaged patients. A number of the training programs have been conducted through State~Aid Heart and Cancer Clinics which have not only served to upgrade the procedures in these clinics but have also improved relationships between clinic physicians and the local practicing physicians who are now making increasing referrals to the clinics. Since the initiation of the CCU training projects in three rural hospitals, twenty-six other stall hospitals have seen fit to develop CCUs. Through stroke and cancer projects SCRMP has succeeded in improving facilities and services in communities of which most are medically deprived areas. In addition the Tri-County Cervical Cancer Screening Project has served to increase the number of routine pap smears being taken by private physicians. While there have been varying degrees of effectiveness among the projects supported during the first three years of operation, the Region has been successful in establishing credibility and cooperation with the more conservative elements of the medical community and the Medical University. the site visitors felt that’the Region's success in this sphere more than compensates for individual project deficiencies. GOALS, OBJECTIVES & PRIORITIES: The program goals and objectives established for the new triennium remain basically unchanged from previous years. The visitors were disappointed to find that the foregoing are highly categorical and aré implemented primarily through traditional continuing education activities. Further, the goals and objectives fail to reflect the broadening philosophies of Regional Medical Program Service. However, the visitors noted that the Region seems to be one that plays according -6- to the book, and probably this triennium application was being drawn together at the time when RMP was still basically limited to categorical and continuing education activities. .— The visitors also considered the fact that given the reluctance with which the medical community has accepted SCRMP, it will not be rushed into accepting new and perhaps "revolutionary" philosephies. In view. of this the visitors still felt the overwhelming problems of South , Carolina imposed a special ‘responsibility on SCRMP to reconsider. , its objectives and to make a concentrated effort in the future to- redirect the program toward activities which will more directly influence . patient care. The goals, objectives and priorities do not seem to be based on a careful assessment of regional needs, but tather randomly selected by convenience and only secondarily seem to fit into a pattern. However, problems and resources do appear to be taken into account | with some regularity and there has been an attempt to make them congruent: with national priorities. The Region's reasoning for not setting ” more specific objectives was that in so doing it would. limit its flexibility to initiate some important activities. Nevertheless, the visitors believed, in order to give the program certain direction, there is a need for objectives to be defined in more specific and measurable terms and set in a time-frame. for accomplishment. While the goals and objectives appear to be publicized throughout the Region primarily by RAG members and the SCRMP newsletter, the visitors had some doubt that many of the people involved in SCRMP truly know or understand them. However, with the development of the Local District Committees such communication is expected’ to improve. ORGANIZATTONAL EFFECTIVENESS: Dr. Moseley, the Program Coordinator, is a : "a personable and fairly effective individual. — He has apparently served, along with Dr. Summerall, who once served as Coordinator, and Dr. McCord the past RAG Chairman, as the force drawing together the various factions of the medical community, some of which were not initially receptive to SCRMP. Dr. Moseley is highly . respected by both members of the RAG, his staff, and apparently by the medical community as a whole. He appears to be providing the moderate leadership necessary to change attitudes in the South Carolina medical community without alienating some of its more conservative elements. While feeling he has been a definite asset to the program, the visitors believed there is a need for him to provide more clearly defined direction to the program and to broaden its scope through direction away from categorical and continuing education emphasis, toward solving some of the more pressing problems of South Carolina ( high infant mortality, malnutrition, patient access to services, lack of motivation of uneducated to seek services). The University or grantee organization does appear to provide adequate support and freedom from a strong policy-making role. The RAG appears to have participation of most of the key regional groups and interests, however, it also has apparent weaknesses. The concern expressed prior to the visit, that the large 70-member RAG might be unwieldy, in itself did not appear to the visitors to be a serious problem, although some RAG members felt it should not be expanded further. The visitors’ major concern was that the 24-member contingency of M.D.s representing the 10 Medical Districts of the State along with the 21 other physician representatives provides an imbalance highly in favor of the M.Ds and the Medical Society, which other members of the RAG find unfair and discouraging to work with. In private conversations certain members stated that some M.D. members only attend those meetings at which critical issues are voted on and then only at the urging of other M.D.s lobbying for certain issues or projects. A recent amendment to the by-laws, which limits consecutive absences to two, has been adopted in hopes of curtailing such practices. The visitors were not, sure that this by-law might not also serve to disqualify some of the minority group members who find it a financial burden, in time lost from jobs, to consistently attend meetings. Aside from two nurses representing the State Nurses Association, there is no other allied health representation on the RAG. The Region states that the allied health representatives will serve on the Medical District Committees and allied health input will therefore be through District Committee representatives to the RAG. The visitors thought this inadequate in that the Region's by-laws limit District. Committee membership on the RAG to physicians, and thus allied health representation will always be indirect. The visitors speculated that an alternative to this problem might be to have each District Committee represented on the RAG by one physician and one member of an allied health profession. Although there are nine Black representatives on the RAG, two of whom were present for the site visit and appeared very defensive of the program, the degree of their involvement remained unclear. The absence of a member of the Palmetto Medical, Dental, and Pharmaceutical Society ( a Black organization) on the RAG , as called for by the by-laws, was defended by the Coordinator who explained numerous invitations to participate have been made, however, there has been no response. : The visitors also questioned the viability of the Palmetto organization since there was some indication that it has declined since Black physicians began to be accepted into the South Carolina Medical Association. However, the team noted that SCRMP did not appear to be very knowledgeable - about the Organization and that further investigation and attempts at cooperation would be in order. The RAG appears to have some, but not strong, policy control over the program. Rather it relies heavily on the Steering Committee and the Categorical Committees for direction. These committees in turn appear highly influenced by the Associate Coordinators on Core Staff; Charles Summerall, M.D., Heart & Stroke, Keene Wallace, M.D., Cancer and William McLain, M.D., Continuing Education. In fact it appears these three individuals along with the Coordinator provide the direction of the program. , The visitors were particularly impressed with the philosophy of the new RAG Chairman, J.W. Colbert, M.D., Vice-President of Academic Affairs at the Medical University. It appeared from his few brief . statements that he envisions a change in direction for the Region. - He placed priority on a clearer identification of needs and concentrated «ffort.on specific health problems among certain identified population groups. in the Region. He indicated new and imaginative approaches — cust be undertaken. and.they must relate more directly to the population being served. The visitors felt Dr. Colbert has much. to offer SCRMP at a time when it needs to broaden its scope. Whether he will be successful in having SCRMP accept his philosophy is questionable and should prove interesting. . . SUBREGIONALIZATION: The site visitors were for the most part favorably a - impressed with the Region's efforts to promote ~ subregionalization. Under the direction of an Associate Coordinator for Medical Districts Program Planning, SCRMP has established. local advisory committees in the ten CHP Medical Districts designated by the Governor. While. these committees will be involved in assessing needs and identifying activity priority areas, they are only now becoming functional to the degree that they have such input. “Each Committee is: represented on the’ RAG by a’minimim of two physicians appointed by the South Carolina Medical Association, a fact which, as cited before results in physician and Medical Society imbalance on the RAG. Along the same lines, the visitors believed the selection of other committee members by these appointed physicians further compounded the physician-Medical Society influence on the Program. The visitors were pleased to learn that the two.CHP (B) Agencies and the Appalachia Agency share committee representatives with the respective District Committees. However, given the newness of District Committees and the weakness of the CHP (B) Agencies nothing of significance has as yet resulted. INVOLVEMENT OF REGIONAL RESOURCES: With few exceptions all of the Region's ; Bo major resources, sparce as they are, are represented on the RAG and appear to be actively involved and committed. The large heart and cancer components make it understandable that the South Carolina Heart. Association and the American Cancer Association have special interests and particular enthusiasm for the program. The South Carolina Medical Association with its large contingency on the RAG, Steering Committee, categorical committees and district committees obviously dominates .the program. While the Medical University's representation on the RAG is relatively small, its influence is exerted more indirectly through the Heart and Cancer Associate Coordinators who serve part-time as Core Staff, but who are, in fact, faculty members at the University. The University representatives appear very closely associated with the Medical Society and respective of its philosophies and supportive of its interests. Involvement of the two CHP (B) agencies, the two Model Cities agencies and the Appalachia Program is indirect in that these organizations do not have voting representation on the RAG but are represented on the Medical Districts Committees. This arrangement the visitors felt to be questionable, in that, given the power structure as established, any impact form these agencies would be from remote positions, In this regard particular concern was expressed over what appeared to be minimal involvement of, and coordination with, the Appalachia Program which is extremely active, and has in two years time provided some 11 million dollars of health-related grant support to Medical District I. While the nursing profession is represented by two members of the State Nurses Association, it. is difficult to imagine that these individuals have much impact given the overall size of the RAG. It was the visitors’ belief that in view of the Region's interest in using developmental funds to determine the feasibility of a physicians- assistant program, which might take the form of nurse~practitioners 5 the involvement of more nurses might be seriously considered. Allied Health Professions representation have been non-existant in the program, a situation which the Region proposes to rectify by the inclusion of such individuals on the Medical District Committees. However, the site visitors felt that, as with Appalachia, Model Cities and CHP, the impact at this level would be lost within the power structure. They believed that given the importance of the allied health professions their impact should be more direct. ASSESSMENT OF NEED: Like most other Regions, SCRMP's assessment of needs is not systematic and admittedly its data- base is inadequate. Program objectives and projects have been developed subjectively on what are considered apparent needs rather than on objectively assessed needs, a method which seems to have worked surprisingly well during the first three years of operation. In view of the recognized absence of resources providing data information, the Region is proposing, through the use of developmental funds, to study the need and organizational plan for.the development of a Department of Community Health Services at the Medical University. One of the many functions of such a department would be to maintain pertinent health care data and provide this in suitable form to the various care and service agencies. PROGRAM IMPLEMENTATION AND ACCOMPLISHMENTS: Core Staff appears competent and its activities have resulted in some action-oriented planning and the development of community organization at the local level. The three Associate Coordinators, have been, to date, the prime movers within their respective sections of the program; Heart, Cancer and Continuing Education, They have had significant influence in determining needs, setting and direction of the three -—1U- programs and on the types of proposals generated. Given the responsibilities these individuals have assumed in the past, it will be interesting ‘to see how their roles will be altered once the Medical District Committees become more functional in assessing local needs and developing ideas for proposals. The two Subregional Assistants appear less directly involved in promoting projects and play more significant roles in maintaining liaison between SCRMP and the subregional areas. They serve to ‘ coordinate and promote between health providers, cooperative activities some of which are supported by SCRMP and others not. , Project surveillance is carries out through the Director of Program Liaison and Planning and Evaluation and his staff of four Program Representatives. While project surveillance and evaluation in the past has been admittedly weak, due to the original projects not having built-in measurable objectives, steps have been taken whereby the project directors, with the assistance of the Liaison, Planning and Evaluation Staff, now include evaluation mechanisms in each project as it is being drafted. The project director and staff will then evaluate quarterly the achievements of the individual projects and annual evaluations will be submitted to the RAG. Program evaluation, like project evaluation, suffers from non-specific, immeasurable program objectives. However, unlike project evaluation, no attempts have been made to identify objectives in terms which can be monitored. The absence of specifically stated objectives, not only creates a problem for Staff in evaluation, but also provides poor guidelines for Staff involved in promoting related activities and -. confusion for potential project sponsors. OPERATIONAL PROJECTS: The visitors felt that while the projects ~~ conducted during the first three years were of less than high quality and only moderately productive,’ they had had significant impact on health in the State and demonstrated an - ability to promote interest within the ten subregions. They also served to provide linkages between institutions, the most significant being between the Medical University and outlying hospitals, clinics and physicians, thorugh these projects much of the skepticism many of the South Carolina physicians harbored about SCRMP has been removed and the confidence of the various health interests of the medical community has been won. The projects which represent the program for the next three years are basically the same quality and designed along the same lines as those of the first three years, categorical and continuing education, and they relate to the overall objectives in the same manner. The visitors had difficulty understanding the high priority given some projects. They did not feel, one project in particular, #51- A Program for Continuing Education for Health Professionals and Allied Health Personnel (which is a T.V. production and broadcast type activity on the campus ‘of the University), could justify its high-priority ranking when considered -11- against the grave health needs of the Region. While the visitors recognized Regions now have responsibility for the technical review and priority-setting of their projects, they believed SCRMP should be made aware of these concerns and encouraged to reconsider the value of this project in view of South Carolina's more serious needs. The visitors believed Project #52 - Health Manpower to be in direct conflict with current RMPS policy, which states that RMP funds are not to be used for direct operational grant support of Health Careers Recruitment projects. DEVELOPMENTAL COMPONENT: The Coordinator identified the same ideas for use of developmental funds as are outlined in the application, which were: to study the needs and organizational plan for a Department of Community Health, Sciences at the Medical University, to conduct studies with applicant hospitals as to ways by which the strengthening of community hospitals can be achieved through regional planning for services, and to conduct studies ag to the regional needs in respect to specific aids in the promotion of health care and services, such as: 1) Physicians Assistant Training Programs, 2) Improved Patient Chart and Record Methods, 3) Computerized Patient Records, 4) Health Services Directories. The visitors were satisfied that the proposals for use of developmental funds are sound and will serve to advance the SCRMP and health care in the Region, Although some concern was expressed that developmental funds would be used in the actual establishment of the Department of Community Health Sciences, Dr. Mosely assured the visitors this was not the case and such funds would be used only for study and planning purposes. READINESS FOR DECENTRALIZED REVIEW PROCESS: In terms of the proposed requirements or standards that a Region's review process must meet before project review authority will be decentralized to it, South Carolina seems to have organized a generally well-balanced and comprehensive review process. It generally includes provision for determining (1) the technical adequacy of proposed operational projects and (2) which proposed activities are to be funded within the total amount made available to the Region. Review Criteria and Program Priorities - The Region has developed what it calls a "Priority Appraisal Checklist," which reflects both national and regional objectives. It includes a section on background (e.g., extent of current deficiency, existing resources); objectives (e.g., nature of target population, extent to which it will affect _ efficiency, and accessibility) ; implementation and methods such as degree of regionalization involved; and finally potential effectiveness and continuation, which tries to measure plans for evaluation, prospects for continuing support, etc. Staff Assistance, Review and Surveillance - There seems to be a good deal of staff assistance in developing projects and moving them through the ~12- review process, although it was felt that the core staff could play more of an advocate role in developing projects to meet overall RMP priorities, as opposed to providing assistance to those projects being developed by institutions in the Region. In terms of surveillance, a quarterly project progress report has been attempted in the past, but the core staff admitted there was a need for stronger surveillance and a greater effort to get an evaluation component into the project at the very beginning, so that progress could. be continually measured. CHP Review and Comment - South Carolina seems to be one of the first ‘egions to have complied with the new policy statement requiring CHP review of RMP applications. Appropriate portions of the application were sent to both the State CHP agency and some 5 Areawide CHP or regional development agencies for comment. There seems to be a good relationship between the RMP Local District Committees and the CHP Health Planning Councils, with shared RMP-CHP membership on the committees which have been established in most of the 10 districts. Sub-regional and Technical Review Structure — There are essentially three levels of review before projects reach the Executive Committee and the RAG. ‘These are the 10 SCRMP Medical District Committees, which review and promote projects in terms of overall local needs and priorities, the four technical review committees; namely,the Heart and Stroke Committee, Cancer Committee, Related Disease Committee, and the Education Committee, which review the projects in terms of both technical merit and committee priorities, and the core staff review. Both the technical review committees and the core staff review make use of the "Priority Appraisal Checklist," as well as specific committee priorities, so that all projects are ranked for any given round of review. RAG Ranking and Funding Determinations - The South Carolina RMP has established a process whereby committee and staff reviews are coordinated. into a final RAG list of project priorities. The Executive Committee receives the reports and recommendations of (1) the medical district committees, (2) the technical review committees, and (3) the core staff. The Committee attempts to coordinate the rankings of the three groups, creating a mix of projects that provide program balance, followed by presentation to the RAg for discussion and decision. Feedback and Appeal Procedure - Although a technical review committee or the Executive Committee can give a project a low priority, only the Regional Advisory Group can disapprove a project and as such is the final arbiter. The opportunity is provided for an applicant to discuss | the proposal at a number of points along the review process, including the technical committees, core staff, or the Executive Committee. If a low priority is given by these committees, the applicant can appeal to the RAG. Feedback includes either reasons for receiving low priority considerations, or changes that should be made in the project to make it more consistent with overall regional objectives and priorities. -13- FEEDBACK TO REGION: At the conclusion of the visit, the chairman of the team met with Dr. Mosely and other SCRMP representatives and identified the following aspects of the program as areas of needed strength: 1. The program remains basically categorical and educational in nature, thereby disqualifying some of the more serious disease problems of the Region and limiting the types of imaginative projects generated ‘for their solution. 2. The composition of the RAG is unbalanced and heavily in favor of the M.D.s and Medical Society interests. Also there is under-representation of allied health interests and the Palmetto Medical Society. 3. While the Region's overall goals and objectives are more specific than most, there is a need for them to be identified in more specific and measurable terms or to establish more specific sub-objectives. Also, they should be more closely related to "assessed needs". 4. Core Staff has functioned to date as a catalyst to persons who have had projects they wished to have funded, not as a stimulator of projects designed to meet specific objectives. 5. While the SCRMP has taken positive steps to improve project evaluation, program evaluation needs additional strengthening beginning with measurable objectives. 6. Although rapport has been established with OEO, Model Cities, and Appalachia Agencies, there is a need for. closer working relationships and coordinated planning. RECOMMENDATIONS: The visitors concluded the South Carolina RMP is ready for triennium review and developmental support. The following support is recommended for each of three years. 1. Approval of Core at: $500,000 2. Approval of project support at: ; $1,127,041 - 3, Approval of develop- merital component at: .$100 ,000 $1,727,041 Project #52 - Health Manpower is in direct conflict with current RMPS policy and inappropriate for RMPS support. GRB/RMPS 4/19/71 SUSQUEHANNA VALLEY Summary Table of Contents Introduction and List of Issues Funding History Geography and Demography Regional Development Regional Objectives Organizational Structure and Processes Present Application Organizational Chart Staff Review of Non-Competing Continuation Application Correspondence Regarding Withdrawal of Project #26 Project Component Analysis Budget Breakouts Summary of Previous Review by Committee and Council wu vr VP Oe oOo . in — —& NO NO NO eS 13 16 17 18 23 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-CDS) 3806 Market Street, P. 0. Box 541 January 1971 Review Committee - Camp Hill, Pennsylvania 17011 | Revised for April 1971 | Review Committee Program Coordinator: Richard B. McKenzie This Region is currently funded at $671,997, (direct costs) for its third | operational year ending March 31, 1971. Indirect costs amounted to $154,402 or 22.9% of direct costs. The Region submits an Anniversary _ Review Application that proposes the following: ‘1. A Developmental Component — 2. The continuation of core and three ongoing projects — 3. The activation of four Council approved but unfunded activities 4. The renewal of one activity _ . _ 5. The implementation of seven new activities 6. The termination of six activities The Region requests $2,111,389 for its third year of operation, $1,560,035 © for its fourth year of operation, $1,575,425 for its fifth year of operation. A breakout chart identifying the components for each of the three years can be found at the end of the: summary. A site visit is planned for this Region, and staff's preliminary review of the application has identified several issues for the site visit team's cansiderstiont oa teenie “ 7 fhe changes in the regional decision-making process which have ~~ * Jed to a shift in program emphasis from primarily a coronary care~ centered program to a more comprehensive one. , 2. Progress in determining goals and objectives and in.setting priorities. 3. Progress in developing regional planning capabilities, both on core staff and at the task force and RAG level, as contrasted with to present practices in planning on a community by community basis. 4, the degree of control maintained on the program by the Pennsylvania Medical Society, which serves as grantee agency. - ; 5. changes in the relationship with thé Hershey Medical School. 6. improvement in the relationship between core staff and the Regional Advisory Group. 7. the extent to which the Region has utilized consultants in technical and specialty areas from within and outside the Region to supplement the efforts of the completely lay staff. - SUSQUEHANNA VALLEY RMP -2- RM 00059 2/71.1 (AR-1-¢ 8. the viability of the newly revised review process. These issues are discussed in further detail in the summary, the attached 8 staff memo and in Committee's January 1971 critique of the > application for. Council _ blue’ sheet). FUNDING HISTORY. Planning Stage . . oo . . a :o € Grant Year Period ‘Funding (d.c.o.) . “OL 6/16 7-5/31/68 $253,530 \ 02 re 6/1/68-3/31/69 | : 250,056. Operational Program . J ; Future ‘Grant Year _ Period . Council approved Funded d.c.o.- Commitmant 01. 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 / Be 545,915 04 4/1/72-3/31/73 650,075 497,644 03 ae! 4/1/73- 3/31/74 483,294 | , C, - - Represents 75% funding of projects 2/ Includes $124,390 in carryover Geography and. Demography This Region consists of 27 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 was enrolled in. 1967; the present enrollment is 147. The Region also has. 55 hospitals. eas is: ‘served | by 1,776 M.D.'s and 218 D.0.'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 Pennsylvaniz 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 hesith department and administrative and staffing patterns, and assurance of SUSQUEHANNA VALLEY RMP -3- RM 00059 2/71.1 (AR-1-CSD) allied health involvement. The Executive Director of the PMS, Mr. MeKenzie, 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. 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 physician 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 equipment funds be made available for physician training. Shortly afterwards three more phoposals were submitted, approved and funded. They were a stroke care unit, a home health gare project and a regional medical information service. New projects submitted during the second year, however, continued to emphasize coronary care. Reviewers found them, on the whole, to bea 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 corporation 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 SUSQUEHANNA VALLEY RMP -4- RM 00059 2/71.1 (AR-1-CSD) selects projects on the basis of a regional plan, rather than just on a community's needs. : : 2 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, 7 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 cartridge 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* $667,997. Regional Objectives The SVRMP frankly admits that its centralized program planning to date re- presents 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 disease 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 heaith 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 basis 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- ialized 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 (Bet iyitice 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. SUSQUEHANNA VALLEY RMP -6-—. RM 00059 2/71.1 (AR-1 csp) 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. ; 7 5 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 fot 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- jials 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- 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 ist 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. SUSQUEHANNA VALLEY RMP -8- 2 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’ — a ‘this course. Then, using the organizational framework of the Pennsylvania... Heart Association and its chapters, these newly trained teams will train. other hospital teams. . 2 _— ar - The wide geographical distribution of emergency teams will be ideal for training local ambulance crews, rescue squads, and other health personnel — throughout the Region. , , .2 a Second Year ‘Third Year : / — oy $15,481. ; $16,066 oo. L , lst Year Project #21 - Enterostomal Therapy Training. The Harrisburg — $9,934. Hospital will conduct twelve, four-week courses. in enterostomal i therapy per year. One student will be trained in each course. Training will include bedside instruction and practice, medical lectures, technical lectures, and conferences. - ae The graduate therapists will be able to. provide patients with stomal care. |. ve and management, thereby freeing nurses and physicians for .other work, In, a addition, the therapists will instruct patients in self-care and teach. allied health personnel the principles of stomal management, oe Second Year oe ee, Third Year $10,439 | | $10,920 Project #25 ~ Altoona Hospital Training Program for Coronary Care lst, Year’. Nurses. This project will provide four, four-week coronary care $59,873 .. training programs per year to primarily registered nurses from woe _the Appalachian-Highland. Area. Training will consist of didactic | lectures and clinical experience in the hospital's classrooms, and will be taught by its physicians and nurses. Consultants from other areas will be called in to teach special subjects. Each ©. “ =. program will teach nurses the use of monitoring equipment, defibrillators, _ and EKG interpretation, as well as specialized nursing skills a required for high quality cardiac care. , - The program is expected to become self-sustaining in the third year through tuistgh fees and.the voluntary teaching and supervisory services of the professionals. Second year - $59,873 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, suchas _ (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 . lst 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 _ vapid 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 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 health ‘care services. _ oe mo 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: I a 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 tised 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 na $159,086 a oe 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 Oc Oo ' Third Year $202,075 - - $210,050 SUSQUEHANNA VALLEY RMP - ll - 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 | rl - | - DIRECTOR i ; i - . . : e - 3 : CL . ~— “t ; . z Asst Director | * . Asst Director . . for . : . : for : Technical Serv a. . Program Devel . - ; jo : r 7 ie sts Yo. Grants { te to Educational . Field. Management | poyster , Communic Activities Service Coordinator i: | ‘Coordinator "| . Coordinator Coordinator Coordinator ee —~e ee ! | | : \ LM 4, | a en man Le _ ] i Research |[} | ' . Application |& Ever | ‘Admin . : | Comaunte }- mursing | Field. «| {Field Field Fielé ew ~ sone So : : : . ‘ 2 . : Specialist Specielis j! roecialist ' Specialist Specialisy, || Represen { Represen Revresen Pepresen i] : ’ . , tart . os . . 4 > 7 . assy . . . Libs Serv ; . ' . . : 2 : : N - _ en ; . Secretary Secretary Secretary]. ° . , * . - Secretary ; . , Secretary : Stace ORGANIZATION . Susqussanna VaLiey Resrenat Mepricat ProcRAM . Mechine - OQverator Dete: Reply to Atin of: Subject: To: ‘-Turus -13- DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC 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 Acting ‘Chief, Repional Development Branch “ > ey Ghief, Grants Management Branch *e ‘ 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 Core $469,700 Project #9, SVE 2MP 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 conmitted amount of $545, 915 for core and three projects, Harold Margulies, M.D. - . December. 23, 1970 - The following staff members attended the December 17. meeting: Miss Dona Houseal, GRB Mr. Dale Robertson, RDB. Mr. George Hinkle, GHB | Miss Mary Asdell, CEB Mrs. Patricia Mullins, PHB 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 wit h 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. > ‘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 necded expertise in continuing education’and allied health. A program development director, systems coordinatgr and a research and evaluation specialist are also being en- ployed. Problems with the Regional Advisory Group caused by poor com- munications have prompted the staff to spend more time personally advising the 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 aumerical ranking system which gives Harold Margulies, M.D. - -— 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 for the Region's third operational year. oe ff Dona E. Houseal Public Health Advisor Grants Review Branch * Action by Director. VP lal Initials (rea . pate__/24/720 -16- January 4, 1972" - Mr. Dale Robertson Programs Assistance Branch Regional Medical Programs Service Health Services and Mental Health Administration Parklewn Building, Room 15 ce 5600 Fishers Lene 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, M.D., which is enclosed with this letter. We are pleased with the honest evaluation offered by this institution and, therefore, must concur with the request. , ° Although Project No. 26 has already been approved by the Hational Advisory Council, it should no longer be considered 4 part of our request for funding in our Annual Application submitted November 1, 1970. . Sincerely yours, Richard 3B. McKenzie Director RBM: Jz Enclosure fo ec; Miss Dona Houseal Mr. George Hinkle Mr. Clyde Couchman @.... RVMENT OF MEDICAL EDUCATION : -17- ROBERT Lb. EVANS, M.0.—DIRECTOR Oo 7 LEON P. ANDREWS, M.D.—-ASSOCIATE DIRECTOR a CHARLES M. REILLY, M.0.—-PEDIATRICS . DAVID M. SHEARER, M,D.--INTERNAL MEDICINE ‘. Al DAVID J. JONES, M.D.--COMMUNITY MEDICINE * THOMAS M. HART, M.D.--FAMILY PRACTICE ——— | | DEC 29 i870 WORK copy. December 24, 1970 Mr. Richard B. McKenzie Director, Susquchanna Valley Regional Medical Program 1104 Fernwood Avenue : Camp Hill, Pennsylvania 170911 Dear Mr. McKenzie: 4 '. appropriations bill recently passed by Congress. as first thought, nor a good use of over $200,000.00. chance of productivity for our people. With waxin best wishes for the Holiday season, Sincerely, yours, . DE ll ~ - Robert L. Evans, M. D. Vice President - Medical Affairs RLE:njh cc; Ellsworth Browneller, M. D., Secretary of Health Harold Margules, M. D., Acting Director, DRMP- ‘ ane . wee YORK roar in reviewing our application for "A Cardio-Pulmonary and CVA Treatment Vehicle", it is our understanding that this applica- _tion has been approved, and is awaiting funding through the Phe original application for this project was made over two and one half years ago, when it was designed as a feasibility study directed at special services to patients suffering from“ coronary and cerebro-vascular problems. In the intervening time, it has been shown repeatedly, both in the United States, _and abroad, that this service has questionable justification. It is probably neither financially or professionally efficient, Although we realize that this project has been approved for funding, and will be funded, we should like to. withdraw our application. We simply do not feel that the project is, at this time, a justifiable use of tax dollars with reasonable We hope you will understand and agree with our decision, and that we may work together in the future on a more productive application. Program Funding: Approved for Current Year Operating level in Cuccent Year (includes. funds carried, forward)------~ Recomacnded Commitment for next year---$ 545,915 COMPONENTS BY DISEASE CATEGORY .- RT Gn-going \ - # Projects 5 Total $8 37,578 258 5,6 Approved /un funded -0- _Disaporoved 8d ee ‘CER On-going # Projects 2 © Total $S 14,042 z3$8 9,1 7 Approved /un funded -0- _Disapproved 02 .OKE On-going _-# Projects 1 Total $S 52,982 % $8 7.9 Approved/unfynded -0- —Disapproved seeesseee- -7--$.666,495 5 671,997 PROPOSED COMPONENTS NEW PROJECTS Tlproject #27-Nurses ’ Dial Access | , a” - Current Operatfonal Year: 02 First. Scheduled AR appl{eation In cycle Region's optional plans: None COMPCHENTS BY TYPE OF ACTIVI —> a Project #29-Computer- ized EKG _ e TRAINING AND EDUCATIGH On-going / # Projects. 4 Total §S 85,872 . °° % $812.8. oO Approved/unfunded O ‘_Disapproved mM Project #32-Central Pa. Cancer Education and Treatment Center at yt DEMONSTRATION OF PATIENT CARE On-going -« @ Projects 7 , _ Total $8 110,925 % $816.5 - Approved/unfunded -Q~- ‘“Disapproved 5 7 AE a ne Re ES HIE ISEY Ca-going # Projects Total $5 “&SS Approved/un funded -Disaprroved > - SLATED DISEASES On-going # Projects Total $$ % SS . Approved/un funded “ Disapproved : JLTICATEGORICAL * On-going # Projects 3 Total $$ 92,195 2 $s 13.7 . Approved/unfunded -O- _Disapproved 1 INERAL Cn-poing I Projects 1 Total $$ 475,200 % $8" 70.7 Approved/unfunded g __Disayproved~ - 0 Se hae em Oh ato UR A nt racer lly ,* ™M Project #28-Automated Computer-assisted Analysis of EEG ¥ RESEARCH & DEVELOPMENT . On-going . oy # Projects Total $$ 4 $8 - _ Approved /unfunded Disapproved h_ Project: #33-Hamilton { Health Center ° - Project #30-Coordinated Home Care Program of Lancaster rT jo Project #31-Family and ‘€ommunity Health Service Program, Ladvcaster - 7 ADMINISTRATION & PLANNIN On-noing | # Projects J} / Total $5 475,700. %$S 70.7 Approved/unfunded 0 Digapproved 0: _=19- Operating level in Current Year (includes funds carcled forwacd)------- $ 671,997 Recommended Commitment for next year~--$ 545,915 Region __ Susquehanna Valley © Program Funding: . : ¢ Approved for Current Yearercrr-r errr ee $666,495 . -2- (Current Operational Year: 02 “First: Scheduled AR application In cycle | . Regton's optional plans: None COMPONENTS BY DISEASE CATEGORY PROPOSED COMPONENTS COMPONENTS BY TYPE OF ACTIVI PART a-potng Approved but Unfunded # Projects 5. , Total $8 37,578 = % $8 5,6 4 - Apreeveghestundes -O- é Project #19-CPR S ots approved 8 Training TRAINING AN D EDUCATION pe # Projects 4 | Total $8 85,872 % $812.8 Approved /unfunded oO pee ey oO Oa-goting # Projects 2 Total $8 14,042 Project #18-Rheumatic Disapnroved 6 %§S 9,1 Fever Control Approved/unfunded -Q- ___Disapproved Ord STROKE . " On-going Project #21-Enterosto # Projects 1 Total $$ 52,982 mal Therapy Training DEMCNSTPATION OF PATIENT CARE On-going ‘ . # Projects 7 , _ Tocal §S 110,925 % $816.5 | Approved/unfunded -O- Disepproved 5 , $8 7.9 oved/unfynded -Q- sapproved $n * ' were el CLDNEY On-going # Projects Total $$ 43S 5 Approved /un funded Misapproves., mae AA, he nl oP i ict a,” RELATED DISEASES Ca-roing # Projects Total $$ % $$ Approved /un funded Disapproved 1 HULTICATEGOR ICAL - On-going # Projects 3 Total $$ 92,195 % $s 13.7 Approved/unfunded -O- Disapproved 1 Sane GENERAL Cn-poing # Projects 1 @::: $$ 475,200 % $8 70.7 Approved/unfunded g Mesapproved - 0 RESEARCH & DEVELOPMENT, . On-going “ # Projects Total $$ % 35. Approved /un funded Disapproved ADMINISTRATION & PLANNING On-coing 4 Projects J Total $8 475,200 28S 70,7 Approved/uatunded 0 Disapproved SUSQUEHANNA VALLEY ~Ot- REGION CYCLE ~ RM 00059__2/7i.1 BREAKOUT OF REQUEST, 03 PERIOD IDENTIFICATION OF CONTINUING {PREVIOUSLY NEW . COMPONENT ACTIVITIES |JRENEWAL tLAPPR/UNFUN. ACTIVITIES DIRECT INDIRECT TOTAL: Developmental | . $54,596 $54,596 $54,596 - | | Core | $469,700 469,700 | $135,150 604,850 #9-Library Info Service 45,614... 45,614 17,419 63,033 #16-Radiation Health Trng. 17,502 17,501; 5,215 | 22,716 #17-Hone Health Service 13,100 ‘ 13,100 | owe 13,100 - | 6R-Geisinger CCU Training 29,425 | . 29,425 | 8,694 38,119 ¥18«Rheumatic Fever Control | 75,217 75,217 | NONE 75,217 #19-CPR | 16,693 16,693 * 16,693 $21-Enteros, Therapy Trng. | 9,934 9,934 * 9,934 ~ '$25-Altoona CCU Trng. | 59,873 59,873 * 59,873 | #27-Narse Dial Access | 29,969 29,969 * 29,969 p28-Automated EEG | 294,470 | 294,470 | "24,810 319,280 b29-Computerized EKG | | | 300,186 300,186 x. 300,186 a~ #30-Coordinated Hone Care | 106,128 | 106,128 | * 106,128 #31-Faxt lyéConm, Health 145,630 | 145,630 [NONE 145,630 p32-Cancer Ed, & Treatent 296,178 | 296,178 | * 296,178 #33-Hemi Lton Health Center | | | 167,175 | 147,175 | * 147,175 TOTAL 545,915 29,425, 161,717 | 1,374,332 p111,389 191,288 2,302,677 * Indirect Costs to be negatiated i ! : t : ! ! REGION SUSQUEHANNA VALLEY CYCLE RM 00059 2/71.1 BREAKOUT OF REQUEST 04 PERIOD IDENTIFICATION OF CONTINUING PREVIOUSLY {| NEW COMPONENT ACTIVITIES iRENEWAL APPR/UNFUN, !ACTIVITIES | DIRECT __'INDIRECT TOTAL Developmental $54,596 $54,596 54,596 Core - ' 9-Library Info. Service Ip 16-Radtation Health Trng. | #17-Home Health Service ¥6R-Geisinger CCU Trng. 31,551 31,551 9,402 40,953 #18-Rheumatic Fever Control 64,417 64,417 NONE 64,417 nw 1S=cPR 15,481 15,481 * 15,481 #2i-Enteros. Therapy Trng. ' 10,439 10,439 *. 10,439 ~ #25-Altoona CCU Trng. 59,873 59,873 * 59 ,873 | 27-Nurse Dial Access 29,453 29,453 *® 29,453 #28-Automated EEG | 82,062 82,062 | 25,925 107,987 | - f29-Computerized EKG . | 300, 186 300, 186 * 300 , 186 bX #30-Coordinated Hone Cate | | 106,367 106 ,367 * 106 ,367 | | bsi-Fantly & Conm, Health | 145,724 | 145,724 | NONE 145,724 ~ #32-Cancer Ed. & Treatment 202 ,075 202,075 * 202,075 ¥33-Heatiton Health Center | { 457,811 | 457,811 * 457,811 | rom =| 31,551 | 150,210 11,378,274 1,560,035 35,327 1,595,362 : * Indirect Costs to be negotiated } | : | | | cae tammy be netsh deat tern Raw Re ee mt emnerte cence aan eeetattamaennen | ae Meme at a RI | ee: i " RM 00059 2/71.1 7 | [) ALL YEARS | ALL YEARS quprRect | TOTAL [| DIRECT | TOTAL [- | ; | § 54,596 $163,788 F 163,788 | | ! . te i. . : i 5 | $469,700 }§ 604,850): \ i V : : z | V19 45,614 Is 63,033 3 | rE J. '517,501 18 22,736} ( | : J on 1'g 13,100. 1S 33,205 0! | ls 60,976 is 79,072 tS 1 | . : i 1'g139,634 i$ 139,634 iw | F_ $16,066 $48,240 |S 38,220 L a | ' § 10,920 -$ 31,293 - [$32,293 | i a4 ! | : | ; i | 18119 ,746 5 119,746 ! | | ! | | a i 1 Dial Access | 1 $30,224 , | $30,224 x Is 30,224 '$ 89,646 |§ 89,646 i | Fo BAutoma ced: | i 1 : : my i ; ot EEG L '9376,532 [$427,267 | . ‘ : i : ; 7 t | ae $300,186 | $300,186 * | 300,186 ‘$900,558 s 900,558 | | i | : i } 14 '6125,400 [$115,400 ; * + $115,400 $327,895 |, 327,895 1 { i ' i Li \ : $159,086 159,086 | NONE | $159,086 $450,440 8+ 450,40 : i . i , { te f i t ign10,050 «= $220,050 | * | s010,050 $708,303 $708,303 | | i | ic i : $678,897 $678,897 | * | 678,897 $1,283,853 $1,283,883 | | i : i | ! 1! : . _ Tole 9 i 0 $26,986 $1,558,439 | #15575 40h ° 1 $1,575f24 $5,246,849 $5,473,408 tr Cests te oc negotiated ' my | 1 || | i : fo ‘ 2 he a po - : wy [-- Le mime i & ~23- (4 Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF 7 Vv fo D 3 JANUARY eee RUARY 1971 REVIEW CYCLE SUSQUEHANNA VALLEY REGIONAL NEDICAL PROGRAM RM 59 (AR-1-CSD) 5/71 ‘ - FOR CONSIDERATION BY APRIL COMMITEE AND MAY 1971 COUNCIL RECOUMENDE TC’: Committee deferred their recommendation 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 ~ $31,551. 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 onsite 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 KP Sf needs additional capabilities in order 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, alli ed 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 sought 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 retain.d 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 Education Council, which has restructured its membership to include wider representation From non-medical professions, SUSQUEHANNA VALLEY RHP . ~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 Geisenger Medical Center CCU Nurse Training Program, the sole such resource in the Reston: The proposer of an already approved project (#26), the York Hospital, has withdrawn its request for a CVA Transport Vehicle because 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 similar systen 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, the Pennsylvania Medical Society. Since there seems to have been much change and redirection of the program, reviewers had difficulty in assessing a reasonsble 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 /GRY 1/19/71 SUSQUEBANNA VALLEY -3- NATIONAL ADVISORY COUNCIL (FEBRUARY 2-3, 1971 MEETING) RECOMMENDATION: Council concurred with the Committee's request that a site visit be eld to determine a funding leve] for the coming year and to assess the Region's progress since the last site visit. Council did approve renewal of Project #6R, Coronary Care Nurse Training at the Geisinger Medical Center, as requested and support for Project #25, Coronary Care Nurse Training at the Altoona Hospital for one year, GRB/2/22/71 + (A Privileged Communication). ‘ SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM RM 60059 5/71 ‘ FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION: The Committee recommended that RMPS provide $100,000 additional funding to Susquehanna Valley RMP with no specific advice as to its use. However, the Region was not approved for developmental component funding as such. The application (submitted jin November 1970 and deferred by February 1971 Council for a site visit) requests: 1) the activation of four Council approved but unfunded activities, 2) the renewal of one activity, 3) the implementation of seven new projects and a developmental component. Critique: Committee recalled that a site visit had been held as a result of February Council's request, in order to determine a funding level for the coming year and to assess the Region's progress since the last site visit. Review Committee and Council at their last meetings had difficulty in evaluating the application because the Region appeared to be undergoing several major changes and.neither group had a member with recent, on-site knowledge of the Region. Because the application showed evidence of continuing difficulties in leadership, regional planning and relationships with the-medical school, a site visit was considered necessary. The findings of the site visit to the Susquehanna Valley Region on March 25, 1971, were reported to Committee. The visitors outlined the strengths and weaknesses of this Region and described the progress since the visit in February 1970. . The excellent grass roots involvement of physicians in each of the four Areas continues to be a major strength of the Region. The site visitors were impressed with the interest of providers in small communities in RMP as a mechanism for improving patient care. The organizational plan, which includes area committees, categorical councils, an executive committee, as well as the RAG, appeared workable. Young physician- chairmen of the Councils have given much assistance to the Core staff efforts. ‘Core, while completely lay, has made some major contributions in program planning. It is also working with CHP in some joint program efforts. The early emphasis on coronary care seems to have broadened as evidenced by proposals in areas such as home health care, comprehensive health care centers, and cancer education. Despite these strong points, there are overriding weaknesses which discouraged both site visitors and Committee members. The most serious problem is the lack of strong direction from any quarter. Neither the Coordinator nor any one on Core staff provides dynamic leadership. The grantee agency, the Pennsylvania Medical Society, is not offering strong support to the program. While the RMP has tended to function as -a subordinate of the PMS, the site visitors learned that the grantee SUSQUEHANNA VALLEY RMP -2- RM 00059 5/71 became so by default, not by any commitment to the program. The Dean of the new medical school at Hershey has been unable to bolster the RMP, because of both his urgent and immediate concerns with starting the medical school and the lack of anyone on Core staff with the professional background to require better commitment from him, The Regional Advisory Group has been weak and reactive to the grantee organization, to area demands and to national priorities and review decisions. At the same time, it has not provided much support to Core, possibly because of the lack of medical leadership on Core staff. In fact, when informed by RMPS that available funds were only $24,313 more then. the current Core budget, the RAG had considered a severe cut-back in Core staff funding. Strengths in the leadership in categorical Councils have not been built in to the RAG. While some RAC members present at the site visit seemed to reassess their evaluation of Core worthiness, the site visitors also attempted to alleviate the untenable funding situation imposed by RMPS by recommending that the Region receive some additional support ($100,000) to preserve the very life of this RMP. ‘The visitors hoped that such an’ amount would preclude expenditure of funds for such projects as the Automated Computer- Assisted Analyses of the EEG, which seemed esoteric and out of line with the Region's more pressing health needs. The $100,000 should enable the Region to initiate some worthwhile project activities and give the RMP some visibility in the Region. Committee concurred with the site visitors reservations about the viability of the SVRMP as a Regional Medical Program. There was disagreement among its members about what course to pursue in light of the problems outlined above. Several members questionned the desirability of investing further support when conditions necessary for improvement did not seem in the offing. Other members, however, believed that the Region had enough promise in its Core staff and community participation to warrant a chance to develop a program. In concert with the site visitors conclusions, Committee recommended that the Region should be informed that national reviewers had serious reservations about the future of the Program and given a year and some additional support ($100,000) to strengthen its leadership and produce a regional plan. The Region should also be informed that careful study will be made of the process by which the Region determines its allocation of funds and sets its program direction, and that medical leadership on Core staff is considered essential. Committee concluded their discussion with the recommendation that both a strong message from the Director, RMPS, regarding Committee's hopes and reservations about the Region and assistance from RMPS staff accompany the feedback of their other concerns. The developmental component request as such was disapproved because of the weaknesses in the decision-making structure. NOTE: There were five dissenting-votes. RMPS /GRB 4/21/71 Date: Reply ta Alin oft Subject: Te: gs “ASO RINE AVES WRAP AL Le ke DEPAR., .cNT OF HEALTH, EDUCATION, AND WreLFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION April 2, 1971 ' Short Summary of Susquehanna Valley RMP Site Visit Findings, March 25, 1971 Directorgl Regional Medtcal Programs Service wie THROUGH: Acting Deputy Director —2//.4)- Regional Medical Programs Service The site visit team consisted of: J. Warren Perry, Ph.D., Dean, School of Heaith Related Professions State University of New York at. Buffalo Bland W. Cannon, M. D., Council member . Manu Chatterjee, M.D., Coordinator, Maine Regional Medical Program Sarah J. Silsbee,. Chief, Grants Review Branch, RMP5 James Smith, Operations Officer, Regional Development Branch, RMPS Clyde Couchman, Regional Office Representative, DHEW Region III, RMPS Carol M. Larson, Allied Health Specialist, Continuing Education and. — Training Branch, RMPS The “site visit was held on March 25 as a one-day meeting in Camp Hill, Pennsylvania. . The visit resulted from Council's decision to defer action on the Region's request for additional funds including developmental funding. The Council felt that it could not make a determination of the Region's progress in decision-making, planning or priorities until an on-site visit was made. Background: This Region has had two site visit teams studying it. - Both site visit reports indicate a concern about where the focus lies on decision-making, planning and priorities. Very early in its development, the Region developed a subarea organization with staff assigned to help area committees develop priorities in the categorical areas. All site visit teams have reported an unusual degree of interest among the pro~ viders that grew out of this development. At the same time, the site visitors noted a lack of overall regional planning which had the areas working out of context of a regional plan. The 1970 site visit found. that a council framework had been developed around the categorical areas and continuing education which was serving as a vehicle for regional planning in the categorical area, However, the overall priorities of the Region and the goals for the program as a whole were still unclear. ‘Both site visit teams reported a lack of understanding about the contri- butionsof the grantee agency, the medical society, the Regional Advisory Group and the medical school to program development. Page 2 - Director, RMPS Since this Region began, there has not been a physician or provider expertise on the core staff. The Council development resulted from recommendations of the first site visit team and last year's team recommended that a faculty member from the Hershey Medical. Center be added to the staff to provide a bridge to the provider community. The Region's proposed projects have seemed to be a series of disparate activities unrelated to one another or to an overail plan. . The. ; application deferred by Council included two expensive computer projects ‘dealing with EKG and EEG techniques. The review process that forwards this type of activity at this point in time was - serious concern to the 1971 Site Visit Team. Findings of the 1971 Site Visit. Team: The site visitors came away with ambivalent reactions to. the Regional Medical Program in Susquehanna Valley. -Quéstions remain regarding the effect of the grantee agency, the effect of the completely lay core staff and the effect of the non- involvement of the medical school on the program. In addition, the Regional Advisory. Group. itself does not seem to have a-clear program direction in mind. Despite this, the site visitors were impressed with the interest generated by providers in small communities that the Regional Medical Program could serve their needs in improving patient care. ‘These needshave been perceived in a categorical framework because the Region believes the original intention of Public Law 89-239 represented the parameters in which they could plan. The core staff has done a good job in promoting this interest. “The grantee agency, the medical society, is not providing leadership or domination to the program in a direct fashion. In fact, the representative of the board stated to the site visit team that the medical society had become the grantee by default. There had been some interest in having the Hershey Medical Center be the grantee but it was unable to take on the job. ~The grantee organization takes its responsibilities for setting up the fiscal procedures and the staffing pattern very seriously, and has involved a management group to come in and lay out the organization staffing, the functions of the Regional Advisory Group, the grantee and the core staff. This has been carefully thought through and is quite clearly worked out. The. core staff is completely lay and looks to Council members as their resource for provider expertise. The team was quite impressed with the amount of time and effort the Council members have given to this aspect of the program. The Council chairmen as a group were young physicians with very good qualifications in their individual fields . but they worked as requested by the core staff. a“ Page 3 - Director, RMPS |Furthermore, the council chairmen are involved primarily in vertical planning in-limited areas, not horizontal planning in overall programn.. The team was impressed with what the core staff has accomplished while working under the severe handicap of token support from the grantee. and the RAG. The core staff simply does not have the composition - specifically, a physician - to demand commitment from the grantee, the medical_center or the RAG. There was some indication that. the core staff does not feel the need for a physician to serve in this capacity. Following up on the 1970 site visit recommendations, representatives of the grantee organization (but not the coordinator) talked with Hershey Medical Center Dean about the assignment of-a faculty member half-time to the Regional Medical Program. The Dean was unable to provide the faculty time; however, core staff indicated that individual faculty members were participating in council activities, particularly in the Education and Manpower Council... During this site visit, the team requested from the Dean-a clear statement of commitment to the RMP from the Medical Center. The commitment was not forthcoming; instead, the Dean aired his frustration about delays in faculty recruitment, lack of financial support from Pennsylvania State University, the parent institution, lack of clear authority to-serve as the University agent for continuing education (at present, Jefferson Medical College has the University contract for -eontinuing education for physicians while the University retains responsibility for continuing education for all allied health personnel). ‘In answer to direct questions, the Dean declared no concern about the medical society as grantee or about the schools under representation on the RAG and lack-of influence in the overall. Program. Clearly, the Dean's immediate concerns preclude much thought about the Susquehanna Valley RMP. The Regional Advisory Group has not been a positive source of leadership or direction; rather, it has been reactive ~ to the grantee organization, to. area demands, to national review decisions and to national priorities as opposed to Public Law 89-239 priorities. Except for several members— at-large, the RAG membership is determined by area committees or organizations which make up the.coalition of interests in the RMP. The council chairmen serve the RAG in a technical review capacity, but are not members. The team learned that the Regional Advisory Group was considering a severe cut-back in core funding, in order to fund several projects. The RAG - apparently perceives core expenditures as "overhead" and project expendi- tures as "program." Thus, when informed by RMPS that the funds available would be only $499,513, or $24,313 more than the current core budget, the RAG wanted to cut the “overhead.” The site visitors were able to elicit sufficient information about core activities which had resulted.in program a @ Page 4 -~ Director, EMPS development, but not RMP projects, that several RAG members were “reassessing their evaluation of core worthiness. The RAG was.to decide on new budget allocations on April 1. ; Recommendations of the Site Visit Team: J. That RMPS provide $100,000 additional funding to Susquehanna Valley RMP with no stipulation as to how the funds should be utilized. The RMPS level does not take into consideration the fact that the Region! Ss commitment included very little project funds. This Region is faced with an untenable funding situation imposed by the RMPS decision. 2. That the Region be informed that national reviewers have serious reservations about its viability as a Regional Medical Program: the lack of clear commitment to, or interest in, an effective program by the grantee, the medical center and the RAG; the capacity of the Region to set priorities and to negotiate local area demands, as evidenced by the projects proposed. 3. That the Region be informed that core staff is functioning well without much help from key groups. Its community participation and involvement are unique and impressive. These two strengths are @ -responsibile for the additional funding recommended. 4. That the Region be informed that the national reviewers recommend additional funding at this time to give the Region a chance to chart | its own destiny without dependence on national review actions, and that the national reviewers believe a physician on core staff would serve ‘the Region well. - 5. That the Region be informed that careful study will be made of the processes by which the Region determines its allocation of funds" and sets it program direction. dM hein. Sarah J. Silsbee ‘Chief Grants Review Branch SITE VISITORS (A Privileged Communication) SITE VISIT REPORT SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM March 25, 1971 _J. Warren Perry, Ph.D., Chairman, Dean, School of Health Related Professions, State University of New York at Buffalo, New York Bland W. Cannon, M.D., Council member, Memphis, Tennessee Manu Chatterjee, M.D., Program Coordinator, Maine Regional Medical Program, Augusta, Maine - REGIONAL MEDICAL PROGRAMS SERVICE STAFF Mrs. Sarah J. Silsbee, Chief, Grants Review Branch Mr. James Smith, Operations Officer, Regional Development Branch Mr. Clyde Couchman, Regional Office Representative © ~ Miss Carol M. Larson, Allied Health Specialist, Continuing Education Branch SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM Richard B. McKenzie, Director James E. Smith, Assistant Director for Program Development - John D. Hoffman, Assistant Director for Technical Services Richard E. Wright, Field Service Coordinator Franklin E. Williams, Educational Activities Coordinator James Patterson, Grants Management Coordinator Robert M. Fisher, Communications Coordinator Ellsworth R. Browneller, M.D., Director of Governmental Affairs, Geisinger Medical Center, former Secretary of Health for the Commonwealth of Pennsylvania, Chairman of the RAG. George C. Williams, ESQ, Wellsboro attorney, Vice-Chairman of RAG and Chairman of its Planning Committee, Community hospital board member John F. Rineman, Executive Director and Treasurer of the Pennsylvania - Medical Society, grantee for the SVRMP, RAG Treasurer John H. Harris, Sr., M.D., Harrisburg radiologist, RAG Executive Committee and Chairman of the Special Board Committee for SVRMP of the Pennsylvania Medical Society Aaron H. Claster, Lock Haven businessman, RAG Executive Committee, a community hospital board member, active in CHP activities J. Mostyn Davis, M.D., Shamokin family practitioner, RAG Executive Committee, the Northeastern Area Executive Committee James C. Kirk, Administrator of Pottsville Hospital, RAG Executive Committee, Northeastern Area Executive Committee, Past President of the Hospital Association of Pennsylvania SUSQUEHANNA VALLEY RMP . RM 00059 ©} Charles A. Laubach, Jr., M.D., Chief of the Cardiovascular and Pulmonary Disease Section, Geisinger Medical Center, Chairman of _ the SVRMP Council on Heart Disease, active in the Northeastern Area Committee, President of the Pennsylvania Heart Association Bernard F. Carr, Superintendent of Altoona Hospital, RAG Planning Committee and the Appalachian-Highland Area Committee, President- elect of the Hospital Association of Pennsylvania _- William Schirmer, Assistant Administrator, Harrisburg Hospital, Treasurer of the Board of the Hamilton Health Center project, now funded from 314(e) funds George T. Harrell, Jr., M.D., Dean-and Director, The Milton S. Hershey Medical Center, The Pennsylvania State University, Member of the RAG, and of the Special Board Committee for SVRMP of the Pennsylvania Medical Society William H. deffreys, M.D., Director of the Department of Neurology and Psychiatry, Geisinger Medical Center, Chairman of the SVRMP Council on Stroke . Roland A. Loeb, M.D., Lancaster cytologist, Chairman of the SVRMP Council on Cancer David D. Pearson, Ph.D., Professor of Biology, Bucknell University, Chairman of the Northeastern Area Committee. Nikitas J. Zervanos, M.D., Director of Community Medicine, Lancaster General Hospital, Member of the SVRMP Council on Facilities and Services, project director of the proposed Family and Community © Medicine Program in present application. DRAFT (A Privileged Communication) SITE VISIT REPORT SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM March 25, 1971 Structure of Site Visit This was a one-day meeting, designed to assess the Region's progress in setting goals and priorities, in resolving differing expectations among the grantee organization, the RAG, the area committees and the core staff, and in enlisting involvement from the Hershey Medical Center. The site visit agenda, as originally developed by the coordinator, called for an early session with the core staff alone, followed by a long session with about seventeen representatives from the grantee organization, the RAG, area committees. the medical center and Councils. RMPS staff asked that the largér group be divided into functional lines for part of the day; instead, smaller groups of cross-sectional representatives were scheduled for the morning and afternoon sessions. The RAG chairman and vice-chairman, as well as individual members from Councils and area committees were present during both sessions. The Hershey Medical Center dean was present for a short time during the afternoon, but was unable to stay for the feedback session at the end of the day. The feedback session was taped for later distribution. With only one day, the site visit team _ wasted no time in getting directly to the point of their visit; so with the cross-representative participation from the Region, the team's persistent probing reached all levels of planning and decision-making at the same time. Initially startled and defensive by the direct line of questioning, the participants then opened up with frank, thoughtful responses. > The Issues as Posed by the Site Visit Team "What has your Regional Medical Program accomplished and what does it hope to accomplish in the next few years? You seem to have amassed the necessary ingredients for a Regional Medical Program, but something is missing and we can't see the Program emerging. Your Region has several unique features. You have the State Medical Society as the grantee, is this a problem in your development. Your Region has a core staff devoid of 'provider' expertise. What have you done to fill that gap? Your RAG seems. to be a coalition of representatives from organizations, is this a factor? Your medical center does not seem to be involved, except for the Dean's membership on the RAG; has this impeded your progress? We realize there are reasons for these unique features and we accept them. But show us what you have done, where you want this Program to go, and why you feel you need additional RMP dollars from the limited funds available." Later, to the Medical Center Dean: "Why isn't the Medical Center more involved in the RMP, for example, in continuing education? Is it the grantee, is it ‘the lack of representation on the RAG, is it the core staff?" SUSQUEHANNA VALLEY RMP -=2- RM 00059 @ Immediate Responses to the Issues From the grantee representatives: The State Medical Society became the grantee by default; the Hershey Medical Center couldn't take on the job. We have employed management consultants to help us map out the organization, the core salary structure, the functions of the RAG, representation on the RAG, composition of the Councils and the Planning Committee. We have followed every suggestion made by national reviewers; last year we asked the Hershey Medical Center to appoint a faculty member half-time to serve on the core staff, as suggested by the site visit team, but the Dean was unable to assign any one. _ From RAG representatives: When is Washington going to give us some clear signals on what it wants. Originally, we planned to make coronary care improvement our major priority, but the National Advisory Council said we had to limit our funding to a few pilot areas. We need project money. The Area Committees, cited previously as our strength, are showing waning interest because Washington's changing signals preclude funding of their _ project proposals. From the core staff: We have been successful in getting help from individual members of the Hershey Medical Center faculty, in planning the physicians assistant forum, and in the Manpower and Education Council. We get medical guidance from the Council chairmen. We have also worked in non~categorical program areas, were the resources used in developing the Hamilton Health © Center proposals which has been recently funded by 314 (e) funds. From the Council representatives: We have developed plans and priorities in the categorical disease areas. With a unique combination of specialists from the clinics and hospitals and area representatives, we have developed feasibility studies prior to project proposals. In the heart area, we have developed an evaluation.approach that involves not only the hospitals which received RMP funds but those that hoped to, but had to find their own financial resources. From the Area Representatives: Core staff have helped us develop project proposals. We need money for their implementation. From the Medical Center Dean: The State Medical Society has always supported the medical center; we couldn't develop the center and serve as the grantee for the Regional Medical Program simultaneously, although later, we may be interested. We are using RMP funds for the library project which provides literature searches and reprints to physicians, the service seems well accepted. We may be able to develop some cassettes for educational purposes. We are glad to make auditorium. facilities available for RMP activities. My faculty is spread too thin now and could not serve on the RAG, perhaps later. I have no authority from Pennsylvania State University to develop a continuing education program for physicians, Jefferson Medical College has a contract for that, the University has responsibility in the allied health education field. Faculty recruitment is behind schedule; financial support from the State © _Umiversity has never materialized. SUSQUEHANNA VALLEY RMP -3- RM 00059 General Findings of the Site Visit Team | 1. The Region is making some progress toward developing its goals, objectives and priorities, although it has a long way to go before they are clearly stated, specific, related to national goals and generally’ understood and accepted throughout the Region. The RAG's _new Planning Committee is tackling the problem with core staff assistance, and with subarea representation built into the RAG, the Planning Group's deliberations could be disseminated throughout the Region. The categorical Councils and the Councils on Manpower and Education and Facilities and Services are other possible strengths, composed as they are of young specialists and area practitioners; however, the Council representatives need to be utilized in broader program planning; at the present time, their skills are limited to vertical planning in a specific area. —_ With this Region's strong community involvement of private practioners interested in patient care, the transition from categorical emphasis to a more comprehensive approach may not be as difficult as in Regions which have not reached the physician at the community level. The subarea categorical committees may be a barrier to this transition. The team heard evidence regarding one area's cancer planning that left grave doubts about the present method of decision-making. One area, having decided to develop a mobile cancer detection proposal for some unclear reasons, was now regionalizing the plan, after consultation with the staff and the Cancer Council. The use of data as an aid to planning objectives and priorities has not been recognized, although core staff is seeking consultation from the medical center for some data studies. 2. The organizational effectiveness is spotty. ‘The coordinator and the core staff have been performing herculean tasks with very little positive direction or support. The team was relatively effective in demonstrating that core staff activities had resulted in program development. The RAG and area committees were apparently measuring program progress by project funding and considering the core staff funds as "overhead." However, the coordinator does not have the background, experience or stature to command the commitment of the grantee organization, the RAG or the medical center. The core staff needs to lave medical liaison to carry on these functions. The site visit team felt that several of the Council chairmen could serve in this capacity, if given the responsibility and authority. The core staff also lacks representation from the allied health professions. In fact, nursing and other allied health influences are scarce throughout the various levels of decision-making. The grantee organization has set up adequate procedures for managing the funds, providing staff services, etc.. Throughthe help of a managemant SUSQUEHANNA VALLEY RMP -4- RM 00059 consultant fund, the functions of the grantee and the RAG have been carefully delineated. The grantee has not provided domination or direction of the program; nor, has it sought leadership from elsewhere. The RAG has not provided leadership or direction; rather, it has been reactive - to the grantee organization, to area demands, to national le review decisions and to national priorities as opposed to Public Law : 89-239 priorities. Except for several members~at-large, the RAG membership is determined by area committees or organizations which make up the coalition of interests in the RMP. The council chairmen serve the RAG in a technical review capacity, but are not members. The subregionalization efforts have been successful in enlisting local representatives in project planning. In the absence of regional goals, the subarea demands have been hard ‘to arbitrate. Also, the subregional representatives seemed relatively unaware of RMP fiscal constraints on_the national level, the RAG reflects this same lack of communication. . Nevertheless, the subregional development of this Program is a strength that can be utilized in program development. 3. The involvement of regional resources is spotty. The medical profession is involved, at all levels: The nursing and allied health professions are involved in projects and subarea planning, not at the regional level. The community hospitals are involved to some extent, board members as well as physicians. The voluntary and official health agencies are involved on the RAG and in the subareas to a certain extent. The medical school is little involved. This is a real problem. The CHP development in this Region is just underway, and members of the RAG and Councils expressed’ concern that their staffs would duplicate RMP core staff. The team suggested that rather await signals from Washington, efforts be made locally to coordinate, complement or assimilate the staff efforts of the two organizations. The team did not get any feeling for involvement of consumers or political representatives. The RAG chairman was formerly State Commissioner of Health. 4. As noted before, the Region has not depended on a data base for planning or evaluation. 5. Core staff has done as well, or better than could be expected. They have developed a health center which is funded through 314(e) funds. They have developed feasibility studies with the help of Council members, and they have looked for other sources of funding for ongoing activities. Neither the operational projects funded nor the ones proposed are exciting. The coronary training projects at Geisinger and Altoona would appear to be good investments and needed. An evaluation Study in coronary care has evolved to encompass many hospitals throughout the Region. The computerized EKG and EEG project proposals are typical examples of this Region's lack of understanding about national funding priorities. SUSQUEHANNA VALLEY RMP -5- ‘RM 00059 6. It is not surprising that evaluation has barely begun, but it has been started in the coronary care field. Recommendations of the Site Visit Team 1. That RMPS provide $100,000 additional funding to Susquehanna Valley RMP with no stipulation as to how the funds should be utilized. The RMPS level does not take into consideration the fact that the Region's commitment included very little project funds. This Region is faced with an untenable funding situation imposed by the RMPS decision. - 2. That the Region be informed that national reviewers have serious reservations about its viability as a Regional Medical Program: the lack of clear commitment to, or interest in, an effective program by the grantee, the medical center and the RAG; the capacity of the Region to set priorities and to negotiate local area demands, as evidenced by the projects proposed. . 3. That the Region be informed of the necessity to have a physician serve a liaison leadership role with the medical society, the medical center and RAG. 4. That the Region be informed that core staff is functioning well without much help from key groups. Its community participation and involvement are unique and impressive. These two strengths are responsible for the additional funding recommended. - 5. That the Region be informed that the national reviewers recommend additional funding at this time to give the Region a chance to chart its own destiny without dependence on national review actions. 6. That the Region be informed that careful study will be made of the processes by which the Region determines its allocation of funds and sets it program direction. > - ' RMPS/GRB REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION ( A Privileged Communication) TRI-STATE REGIONAL MEDICAL PROGRAM RM 00062 5/71 Medical Care and Education Foundation Inc. April 1971 Review Committee Two Center Plaza, Room 400 Boston, Massachusetts 02108 - Requested 01 02 03 Program Period 6/1/71-5/31/72 6/1/72-5/31/73 6/1/73-5/31/74 Total Direct Costs $463,292 . $368,595 $381,513 $1,213,400 Indirect Costs -0- -0- -0- -0- Total $463,292 $368,595 $381,513 $1,213,400 History: In November 1970, Council reviewed the Region's total program and ite Triennial application, and concurred with the favorable report of an October 1970 site visit. Council concluded that the Region had devel- oped the capacity for self-determination; had set realistic, timely and accep- table goals and objectives; and had adequate decision-making processes as well as management and evaluation capabilities. Although the Council approved level of funding for the Region's Triennial application during the next three years is $2,261,685, $2,015,591 and $2,043,035, RMPS fiscal restraints will only permit $1,722,474 funding and commitment for these periods. Present Application: The application contains one kidney disease project, which is also to be reviewed by an RMPS Ad Hoc Panel on Renal Disease on April 14-15, 1979. Project #13 New England Regional Kidney Program Submitted by the Tri-State RMP, this three-year project proposes to establish the New England Regional Kidney Program (NERKPRO) to assure that no person will die of kidney failure because of a lack of funds, or lack of a plan to be treated on knowledge of what igs available. The proposal is in three parts. Part I - A general introduction documenting need and resources, As a result of a recent series of meetings sponsored by the Tri-State RMP, a group of leading nephrologists and other interested persons joined to develop WERKPRO. (See Apendix X: Minutes of NERKPRO Meetings - Durham, New Hampshire; — pp..107+138). There is general agreement that NERKPRO must meet several basic TRI-STATE RMP -2- RM 00062 5/71 needs: 1) a present need for more cadaver organs; 2) the need for larger pools of prospective donors and prospective recipients; 3) professional training programs are needed for physicians, nurses and technicians in the fields of hemodialysis, organ harvesting, organ transplantation, and tissue typing. Boston and New Haven are major transplant centers, and others are in the pro- cess of being developed in the region. Transplant centers are also centers for professional education and training in kidney disease. In addition, Boston is the location of the Interhospital Organ Bank (10B), a clearinghouse for matching cadaver organs with potential recipients. _NEW ENGLAND FACILITIES FOR END-STAGE KIDNEY DISEASE Central Support: Interhospital Organ Bank Massachusetts General Hospital - Boston, Massachusetts Dialysis Units: Boston Boston City Hospital Lemuel Shattuck Hospital Massachusetts General Hospital Peter Bent Brigham Hospital University Hospital Veterans Administration Hospital St. Elizabeth's Hospital Other Massachusetts Babcock Street Unit, Brookline Lakeville Hospital, Lakeville North Shore Regional Dialysis Unit, Beverly Springfield Hospital, Springfield St. Joseph's Hospital, Lowell Worcester Memorial Hospital, Worcester Transplant Centers: Operative Boston City Hospital Harvard and B.U. Services Massachusetts General Hospital Peter Bent Brigham Hospital University Hospital Veteran Administration Hospital Yale-New Haven Hospital Maine Maine Medical Center, Portland Connecticut Yale-New Haven Hosp., New Haven Hartford Hospital, Hartford Veterans Administration Hosp., West Haven - Bridgeport Hospital, Bridgeport St. Vincent's Hosp., Bridgeport Danbury Hospital, Danbury Waterbury Hospital, Waterbury Hospital of St. Raphael, New Haven e°. TRI-STATE RMP -3- RM 00062 5/71 Part 2 - An_application for funds to finance regionalization of the operations of the Inter-hospital Organ Bank. Reor ganization of ‘the 10B is a major component in the development of the NERKPRO program. The “bank, a non-profit organization, is actually a center for information, expertise, the performance of technical functions (tissue typing), and administration of organ allocation. Major functions of the I0B include: 1) Education and information efforts, primarily with physicians, to encourage the "harvesting" of cadaver organs suitable for traneplantation; 2) Operation of a central office: (a) serving as a communication center through which information on organ availability, suitability, and demand can be ex- charged, (b) maintenance of a central registry of persons avaiting transplant and of potential donors, and (c) administration of a system for détérmining the: allocation of cadavar organs available among the patients awaiting transplant, using information determined by central serotyping laboratory; and 3) operation of a central serotyping laboratory. oF The I10B is currently supported under a contract from the Kidney Disease Control Program, RMPS, and funds from the Massachusetts Department of Health. The IOB has begun charginé fees for serotyping, and is negotiating with third party payers to make these and related costs reimbursable. The IOB is in the process of expanding the field of operation to serve the entire New England region. Financial assistance is needed to support the IOB during this transitional stage when: (1) the I10B is expanding its physical capacities, geographic coverage, and training activities, (2) support from the Kidney Disease Program, RMPS is being phased out, and (3) income ¢rom fee-for-services is not yet suffie cient to support these operations on a full or regular basis. (Pages 47-53 of the application describe steps to be taken to facilitate expansion of the I0B.) A total of approximately $166,000 is requested for the first year support of the I0B as follows: $128,289 personnel; $22,524 supplies; $15,300 equipment. Part 3 - Describes the steps to be taken in developing the remainder of the rogram components so that at the end of the grant eriod, a coor- dinated regional program will exist. The development of the program will be administered by George L. Bailey, M.D. with the advice of NERKPRO, its Scientific Advisory Committee and other com- mittees. In addition to the I0B, other program elements will be developed as follows: Development of Programs and Standard Setting: NERKPRO through its Scientific Advisory and other committees will offer advice to any group con- templating development of a kidney program (Pages 28-29). Professional Training: Is discussed on pages 29-35 of the application. The applicant notes that present RMPS guidelines exclude the support of physi- cians fellowships. If funding becomes available, a fellowship training program in nephrology or transplant surgery would be implemented. Support is requested for the training of: (1) Dialysis Nurses, (2) Transplant Nurses, (3) Dialysis Technicians, and (4) Tissue Typing Technicians. TRI-STATE RMP -4- RM 00062 5/71 Continuing Education: (1). Nurse Consultants in Dialysis and Trans~ plantation will be available for any program in the region to assist with specific problems, demonstrate new techniques to remote centers, and act as advisors to areas starting new programs. (2) An annual two-day workshop on new developments in dialysis and transplantation will be held for nephrolo- gists, transplant surgeons, immunologists, nurses, and technicians. (3) Short (up to two weeks) individual training courses to update skills will be spon- sored. Organ Procurement: Lay and Physician Education: As presented on pages 33-35, this would involve: (1) Training organ harvesting teams, (2) educating the general public to increase their willingness to be donors and recipients, and (3) increasing the awareness of the physician in general practice con~ cerning the desirability and practicability of treating end-stage kidney disease. The Funding Desk (Pages 36-43): This desk would serve three basic functions: (1) Serve as a clearinghouse for information concerning presently available sources of financing; (2) collect data on third-party payer experience with reimbursement for kidney disease and other catastrophic conditions, and would develop proposals for more systematic funding of these conditions; (3) under- take special investigations into the impact of prospective changes likely to effect financing of end stage kidney disease over the next. few years. Registry of NERKPRO (Pages 44-46) The registry functions would include: 1. Maintenance of an up-to-date registry of all potential cadaveric " transplant recipients in order to provide the necessary information for the equitable sharing of cadaver organs. 2. Registration of all live related donor transplants for purposes of follow-up on succéss rate, funding profile, statistics, etc. 3. Registration of all dialysis patients indicating whether center, satellite or home; source of funding; location; etc. 4, Registration of every physician, nurse, or technician trained in dialysis, transplantation or tissue typing in New England. 5. Registration of every dialysis and transplantation facility noting their patient capacity, training capacity and costs. A total of approximately $297,000 is requested for this part of NERKPRO (does not include I0B costs) as follows: $74 ,829-personnel ; $5,000-consultants; $7 ,360-furniture 5 $16,000-travel; $142,200-training and continuing education; $19,270-rent and telephone; $11,020-postage and special transportation; and $21,500-computer time and fees for harvesting organs. TRI-STATE RMP -5- RM 00062 5/71 The Appendices of the application contain copies of 52 letters of support and participation; by-laws, rosters and other information for the IOB; Teaching Protocol for Twin-Coil Machine Dialysis; Funding of Renal Patients in New England; Minutes of NERKPRO meeting; and curriculum vitae of key personnel. RMPS/GRB 3/9/71 « (A Privileged Communication) ’ , & SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE TRI-STATE RECIONAL MEDICAL PROGRAM RM 00062 5/71. ' FOR CONSIDERATION BY MAY 1971 ADVISQRY COUNCIL ! RECOMMENDATION: Deferral for a site visit | : » Year Reqttest - Recommended Funding “1st $463,292 -0- 2nd 368 ,595 -0- 3rd: 381,513 -0- TOTAL . $1,213,400 -0- During its review, the Committee did not have access to the recommenda~ ~ tion of the Ad Hoc Panel on Renal Disease, since the two groups met simultaneously. . From a program point of view the Committee believed the proposalwarranted support. The Panel believed further technical evaluation by a site visit was warranted. Committee Program Critique: The reviewers, including an individual \ who served as chairman of the October 1970 triennial review site visit, were favorably impressed with the proposal. . The Committee found this to be a well-thought out and well presented program, which is in keeping with the regional activities of the Tri-State program. Further, the reviewers believed that the RMP had the capability to ‘earryout its plans as presented. The Committee realized their | ' favorable recommendation was subject to a satisfactory technical review by the Ad Hoc Renal Panel. - - Panel Technical Critique: The Panel's recommendation for deferral with a site visit. was based on the following concerns: 1) There were serious reservations as to whether the appropriate individuals within the .six “| states had had ample opportunity to review the proposal in its final - form to determine the degree of collaboration and cooperation that would . be yequired; 2) The budget seemed extremely excessive; 3) The extent of participation by the Board of Governors could not be clearly determined; and 4) Due to the magnitude of the program, further detailed. evaluation _ of its many facets seemed warranted. . Dr. Edmund Lewis was not present during the discussion of this application. -RMPS/GRB 4/21/71: REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) WESTERN PENNSYLVANIA REGIONAL RM 41-03 (AR-1-CD) 5/71 MEDICAL PROGRAM April 1971 Review Committee 501 Flannery Building 3530 Forbes Avenue Pittsburgh, Pennsylvania 15213 PROGRAM COORDINATOR: F.S. Cheever, M.D. PROGRAM DIRECTOR: Robert R. Carpenter, M.D. This Region is currently funded at $1,248,391 (direct costs) for its second operational year ending June 30, 1971. $226,350. of this amount represents unspent first-year funds reauthorized as carryover into the second year. The Region currently receives indirect costs of $272,633 which is 21.8% of the direct cost award. It submits a triennial application that proposes: I - A Developmental Component Il - The continuation of Core and 7. ongoing activities III - The renewal of one activity for 2 additional years LV - The implementation of 5 new activities, one of which is a revised kidney disease proposal previously returned for revision Vv - A budget for the second and third years of the triennium that requests growth funds for activities currently in the planning stage but scheduled for later activation The Region requests $1,757,550 for its third operational year, $1,970,875 for the fourth and $2,233,286 for the fifth year. A breakout chart -identifying the components for each of the three years follows on the next page. This Region is to be site visited March 10-11, 1971. Staff's preliminary review of the application has identified several issues for the site team's consideration. These are also covered briefly in this summary. FUNDING HISTORY Planning Grant Year Period Funded (direct costs) Ol 1/1/67-3/31/68 (15 mos.) $271,736 02 4/1/68-6/30/69 (15 mos.) 354,234 Operational Program Ol 7/1/69-6/30/70 934,041 02 7/1/70-6/30/71 1,248,391 The Region has been advised that its funding level for the upcoming year must be held to $863,996 due to overall budgetary constraints. RECION Western Pennsylvania crcLe RM 41 5/71 - ~Triennium BREAKOUT OF REQUEST 03. PERIOD ESL EIFICATICN OF (PREVIOUSLY {NEW : [noe PONENT (APPR/UNFUN, !ACTIVETIES | DIRECT INDIRECT TOTAL | Developmental !100, 000 100,000, 20,000 | 120,000 | Unspecified Projects. [ woe . --- aan - woe — | CORE ! 694,385 | 694,385 | 204,740 | 899,125 fl Regional Faculty - ! 35,450 35,450 8,715 | 44,165 ro Hypertension 97,500 | 97 ,500 | 41,195 i 138,695 ;#3 Coronary Nurses i 118,486 118,486 | 53,567 492,053 | #4 ERT Training | i 26,875 26,875 | - 5,823 32,698 . ia Library System 50,000 | |. 50,000 | 23,266 : 73,266 ~ |#6R Nursing Home 143,445 | 163,445 | 68,889 |} 212,334 | #6 "Laurel Home Health Aides 75,000 | | 75,000. | --- 75,000 : '#9 Cancer Chemotherapy i 44,820 | + 44,820 7,933 52,753 (#10 Early Coronary Care | 37,424 37,424 --- 37,424 : ! — a Sickle Cell | ‘ $0,000 50,000 | 19,127. ! 69,127 #12 Diabetes Mellitus. 3 ! 4 50,000 50,000 20,900 70,900 ! 13 Pulmonary Disease a 62,115 : 42,115 | 22: 42,115 | #4 Renal Disease ‘192,050 | 192,050 --- 192,050 | ; : , | , i , cae tounge | man) anser” fraie [anes | TOTAL j }»142, 516 (143,445. | (471,589 1,757,350 1 474,155 {2,231,705 ! | : + i } i — | -, 2 REG LON Western Pennsylvania . CYCLE BREAKGUT OF REQUEST 04 PERIOD -{TDENTEFLCATION OF | CONTINUING i {PREVIGUSLY { NEW . iCOMPONENT ;ACTIVITIES RENEWAL :APPR/CNEUN, [ACTIVITIES | DIRECT INDIRECT TOTAL ! i , | Developmental | 100,000 100,000 | 20,000 120,000 i | ' i Not | Unspecified Projects | : 400, 000 400,000 Specified -400, 000 ‘ CORE 828, 000* | 828,000 1 240,700 | 1,068,700 i : i i ° t i #2 i --- --- --- i : i i 3 | : we toe |e i i ; n | fe | | #6R 146,337 j 146,337 | 72,333 | 218,670 $8 | 80,000 ! | 80,000 | --- 80,000 ” 1 #9 | 46,995 46,995 | 8,318 55,313 i { i i; #10 = = --- | : i i ! ‘ i . : 1 1 i co ' | ‘#12 ' 60,000 | 60,000 i 25,080 ! 85,080 ; #13 ‘34,378 34,378 n-- 34,378 — . 5 I : #14 1 : 275,165 "275,165 9} --- i 275,165 4 : : : j : ; } | | : | | ! : 7 | | ; TOTAL 954,995 | 146,337 | i 869,543 1,970,875 366,431 2,317,306 . { i : : ; * Includes Central sibeard Service { ' ; i _ i -¢~ me heparees Gea Tye aes BEA wath Ce PEs T — op) oe wea = ” ‘ 4 = wate = i a .-e . I ! vete LE ‘ meen ee ee : t a: 7 wore mens bom tte Dose ae os ~ oy ‘ . ” ath e aN we, oe ee ro) r I ‘Developmental ‘Unspec. Proj. bm eee 450,000 908, 000% | ; 100,000 42,000 ‘100,000 . 20,000 120,000 300,000 _"__360,000 870,000. Specified :-870,000° 1,270,000 1,270,000 _ _ | 908,000 . 265,600 1,173,600 2,430,384 3,141,425 _. : eee 35,450. we oe : 1,362,800 44,165 42 ! | : “- 97,500. 138,695 3 ie 3 : : wn- 118,486 172,.053___. #4 ! ! Ls 26,875 _|__32,698 4 AT. : | . --- _____ 50,000 __ 73,266 _ #6R | : : wee 289,782 | 431,004 “8 - __ | w-- 155,000 155,000. #9 44800 4,800 850 _- 5,650 96,615 113,716. #10 . -- --- --- 37,424 37,424 ne ! | : wee kee ee 50000694227 “$12 ee ! --- -o- --- 110,000 155,980 n3 . : ee — 76,493 76,493 #14 _ 350,486 350,486 _ --- 350,486 g17,701__ 817,701 De : WESTERN PENNSYLVANIA RMP ~5- RM 41-03 (AR~1-CD) Geography and Demography The Western Pennsylvania RMP covers 28 counties, six of which also have ties with surrounding RMPs. The population is approximately four million excluding the three shared counties which have predominant ties with other regions. The three major metropolitan areas in the Region, Pitts- burgh, Altoona and Johnstown, all are reported with declining populations in the 1970 census. The mountainous nature of the area has resulted in traditionally isolated communities. The western border of the State is the Region's border although the Region reports significant interest in Western Pennsylvania activities by residents of the Youngstown, Ohio area and the Steubenville, Ohio ~ Weirton, West Virginia areas. The West Virginia border on the south rather accurately reflects the southern border with some fringe overlap. To the north, three ‘counties, Erie, McKeon and Potter, appear to relate more closely with Western New York. The eastern border of the region is probably best considered as being in the area of Bedford, Blair, Center and Cameron Counties. Bedford, Blair and Center also relate to the Susquehanna Valley Region. The Region has one medical school - in the University of Pittsburgh - and is served by approximately 4,100 active practicing physicians and 15,500 active nurses, 13,000 of which are located in hospitals. There are 12,300 LPNs in the area and 137 nursing homes with approximately 10,000 beds. The school of Allied Health Profession in the University of Pittsburgh, was established within the last three years. There are 43 Schools of Nursing in the Region, almost half of which are in Pittsburgh. Ninty-four acute general hospitals are located in the Region with a combined total of 19,150 beds. Regional Development In the summer of 1965, the Dean of the School of Medicine met with approxi- mately 50 medical and hospital leaders in Western Pennsylvania to discuss the recently enacted legislation creating Regional Medical Programs. It was agreed that the Dean should proceed with an application for funds to support RMP planning. The Hospital Council for Western. Pennsylvania endorsed the plan and the Hospital Planning Association of Allegheny County made available a staff member who assisted a working group of faculty from the Schools of Medicine and Public Health in the preparation of an application. The University Health Center of Pittsburgh (a corporation composed of the four large independent. hospitals affiliated with the University of Pittsburgh for teaching, training and research) was designated as the applicant organization, and a five-man steering committee was formed (Drs. D. A. Clark, Campbell Moses, K. D. Rogers, and Messrs. R. M. Sigmond and Steven Sieverts). A 32-member Advisory Committee was appointed by Dr. Cheever who was the Dean at that time. WESTERN PENNSYLVANIA RMP . -6- RM 41-03 (AR-1-CD) The initial planning year was funded beginning January 1967 and in general, the Region was a very slow starter. The first planning year was extended, without additional funds, for a three-month period. This action was taken following staff's review of the first year's progress reported by the Region which generated deep concerns. Most of the difficulty seemed to stem from lack of full-time leadership and failure to attract promising staff. In January 1968 Dr. Robert Carpenter joined the staff and the following June became the full-time Director. The organization was streamlined, staff was recruited and progress became evident. There was a deliberate effort to regionalize early and nine area advisory committees were formed. The Region's Grant Review Committee met in October 1968 to consider twelve operational proposals which constituted the genesis of the Region's opera~ tional efforts. The Regional Advisory Committee approved the following seven proposals of the original twelve for submission to RMPS: #1-Establishment of a Regional Postgraduate Faculty of Medicine #2-Hypertension Management, University and Selected Regional Hospitals #3-Regional Program for Nurses in Heart Disease, Cancer and Stroke #4-Emergency Resuscitation Team Project #5-Regional Program for Treatment of Kidney Disease #6-Program for Long-Term Training of Nursing Home Personnel #7 -Establishment of a Regional Medical Program Library System These activities, combined with Core, constituted the Region's first opera~ tional application requesting $2,034,413. Following receipt of the application, RMPS site visited the Region in February 1969. The visitors found that previous problems identified during the planning period had been quite satisfactorily resolved and there was consensus that there was great potential in the Region. The team recommended funding for six of the seven proposals; the kidney project was returned for revision. The visitors noted, however, that the impetus of project activity was still based centrally in the university setting and that there was impatience within the Community Involvement Committee regarding the extent of attention to the urban poor. The April 1969 Review Committee accepted the site team's recommendation of a first operational year funding level of $1,060,883. May 1969 Council reduced the recommended level to $934,041 for the first year because of a temporary "hold" on all cardiopulmonary resuscitation projects (the Region's proposal #4). After the special review of the proposal, the project was later funded at a reduced amount. During the Region's first operational year, it submitted two additional proposals: #8, Laurel Mountain Home Health Aide and #9, Training of Cancer Chemotherapists for the Community Hospital. These activities were approved but no additional funds were awarded to activate them. However, the Region activated project #8, at a sharply reduced level, at the beginning of its , second operational year through carryover funds, and two months: later activated project #9 at a somewhat reduced level through rebudgeted funds from Core and three projects. WESTERN PENNSYLVANIA RMP -7]- RM 41-03 (AR-1-CD) The Region's application for its second year operational funding included the amount of the commitment, plus a request to use $235,000 balances from first year funds. They proposed to use these funds in two ways: (1) to conduct six feasibility studies and (2) to activate the aforementioned approved but unfunded activity and to replenish the retrenched budgets in most of the remaining projects. Staff's review of the progress reported on the first year of operations and the plans described for the second year led to a consensus that the Region had exhibited growth and maturity under vigorous leadership of both the Director and Core staff. An award was made beginning July 1, 1970 in an amount of $1,160,391 which represented the full commitment plus $226,350 reauthorized carryover. Under the Anniversary Review and Award system, this Region had no options to submit requests for additional operational activities during its second operational year. The present application reflects the Region's decision to submit a triennial application on its anniversary rather than an appli- cation geared only to its plans for next year. In this regard, staff concluded in its review of the application that the Region had developed a viable and attainable plan for the next three years. The following chart displays the Region's funding status at the time this application was developed; the levels of funding for the continuing life of ongoing projects and specific new activities, as well as the effect of its growth funding request: Projected F the Tri . Present Funding 1st Year 2nd Year 3rd Year Central Services Core staff activities $594,191 $694,385 $798,000 $878,000 Central Library Service -0- -0- 30,000 30,000 Developmental Component ~0- 100,000 100,000 100,000 Project Activity ; Ongoing projects and 654,200 — 591,576 273,332 4,800 their continuation or Renewal Specified new projects -0- _ 371,589 369,543 350,486 and their continuation Unspecified "growth" -0- -0- 400,000 870,000 activities and their (inc ludes continuation $420,000 , for new activities) $1,248,391 $1,757,550 $1,970,875 $2,233,286 WESTERN PENNSYLVANIA RMP -8- RM 41-03 (AR-1-CD) Organizational Structure and Processes The Regional Advisory Committee, originally developed as a 32-member body now is composed of 48 members. It reflects good geographic and discipline representation. The Executive Committee is composed of, the Chairman and the Secretary of the full Committee and the Chairmen of the following - specialized Committees: Operational Grant Review Committee By-Law Committee Nominating Committee Community Involvement Committee Heart Committee Stroke Committee Cancer Committee ' Health Care Education Committee While the full membership of the Advisory Committee and its sub-committees displays very good geographic distribution, the Executive Committee reflects predominantly Pittsburgh representation. However, this Region developed Area Advisory Groups early on and is presently functioning with nine such groups involving some 465 persons committed to improving medical care in their areas. Under Appendix C, in the application, the planning accomplishments of each area and its participation in the Region's ongoing activities describe good regionalization. The Area Advisory Group structure is similar to the Regional Advisory Committee in that categorical sub- committees have been formed. , These Committees, both at the Regional and Area level, serve to identify needs, design the outlines of projects required to meet those needs, and identify leadership for the projects. In addition to these Committees, the Region utilizes the Task Force approach with a Task Force on Primary Care being recently appointed. Consultants are used to make site visits to review proposed activities and evaluate ongoing projects. All operational proposals, whether stemming from Area Groups, Committees of the Regional Advisory Committee or Core staff identification, are reviewed by the Operational Grants Review Committee. That Committee recommends priorities among the proposals. Following this review, the proposals are submitted to the Regional Advisory Committee. The upcoming site visit will afford an opportunity to inquire into the specific processes of this system and will report on its effectiveness. Regional Objectives The twelve program objectives established by the Region have been assigned three priority weights - highest, high and important. Briefly stated they are: , Priority Objective Highest #1 - To assure that modern coronary care is available to all residents in the Region WESTERN PENNSYLVANIA RMP Td Priority High High High _ High High @ neh High Important Important Important Important -9- RM 41-03 (AR-1-CD) Objective #2 - To develop the Region's system for primary care by providing ready access for rural and urban areas to the health care system #3 - To develop an adequate continuing education program for the health pro- fessionals in the Region #4 - To develop in hospitals caring for cancer patients, groups of health professionals with specific competence in oncology #5 - To develop a Regional network of facilities to support patients with chronic renal disease and to improve the care of patients with acute renal. disease #6 - To define the most adequate care programs for patients with stroke #7 ~ To develop projects to attack diabetes and emphysema #8 - To provide adequate extended care and long-term care in an effort to limit the health care costs. #9 - To continue to document the health care problems of the Region #10 - To stimulate a public information program, using existing agencies, parti- cularly the community hospital #11 - To improve the treatment and care of heart disease other than coronary heart disease #12 - To expand the area of impact of existing projects Within these objectives, the Region has developed a strategy for each activity with a time schedule and identified leadership roles. This consti- tutes the operational plan for the Region. In reviewing this portion of the application, staff felt the objectives and priorities were clearly stated and well related to the Region's capabilities and opportunities. Heart disease, by virtue of the more abundant opportunities to act in this area became the highest priority categorical concern. WESTERN PENNSYLVANIA RMP -10- ' RM 41-03 (AR-1-CD) Present Application The Developmental Component. The Region requests developmental funds of $100,000 for each of three years. a The ability to move expeditiously to solve problems is cited by the Region as an important factor to program growth. Western Pennsylvania RMP made extensive use last year of reauthorized unexpended funds to carry out 4 variety of feasibility studies to move into this area. oo Specific approaches are described as to how the proposed developmental funds will be utilized in the areas of Coronary Care, Primary Care, Continuing Education, Cancer Care and Stroke Care. Generally, the approaches may be described as planning studies, specific investigations, demonstrations, and seed money. The review process to govern the investment of developmental funds is the same as that which exists for review of investment of other program funds. However , requests for support limited to 12 months and less than $10,000 may be approved by the Director subject to review by the Advisory Committee. Invest~ ments of longer duration and requiring greater funding will be reviewed by a site visit team, the Operational Grant Review Committee and the Advisory Committee. All developmental component activities must have the approval of the appropriate Area Advisory Groups. Request for Growth Funding In the Second and Third Years of the Triennium The Region projected both its operating plan and its budget based on several hypotheses. One of these is that the program base would be permitted fiscal expansion in 1972, provided adequate numbers of good proposals were submitted to RMPS. Another was that it would be necessary to develop program support from non-Federal. sources if true partnership is to evolve between the Federal and private sector. The budget request for the second year of the triennium (the fourth operating year of the program) includes $400,000 for projected growth activities. In the main, these activities are now in the study and planning stage with time schedules plotted and leadership roles identified. Some are reflected in the grid included in the annual report of the Regional Advisory Committee and others are expected to generate from Developmental Component activities. For example, the Pittsburgh Model Cities Program is identified for a leadership role in a program scheduled for activation in July 1972 to assist local pro- viders to link institutions in the Pittsburgh Model City Area to develop a comprehensive primary care and referral system for the area residents. The budget request for the third year of the triennium includes $450,000 to continue the activities inaugurated the year before, and $420,000 to initiate new ones. Presently funded projects are scheduled for termination in these’ years, so that. while the net effect is a gradual increase, the budget becomes a revolving account. The site visit team plans to learn more about these leavening activities and will report to the Committee on them. WESTERN PENNSYLVANIA RMP ~l1- RM 41-03 (AR-1-CD) Requested Third Year CORE (First Year of Triennium) $694,385 Core is presently supported at $594,191 of which approximately $75,000 is reauthorized unspent program funds from the preceding year. The Region estimates a balance of $27,000 in this component this year. The current staff consists of 35 full and part-time personnel. Two existing professional positions are vacant and are currently being recruited (a Cardio- logist and a Graphic Artist). This application requests three new professional positions in the first year of the triennium--an Assistant Director of Evaluation, an Assistant for the primary care program and a Nurse Specialist in continuing education. In addition, two new technical positions are requested and additional secretarial help. The core budget escalates in years two and three due to limited staff additions, salary increases, and the inclusion of an ongoing operational project (#7 Library System) as a regional resource. The “other category shows a marked increase in the second year of the triennium due to a doubling of the rent in‘a lease negotiation. Similar increases are shown in the supplies category due to the inclusion of the photocopying charges which move to the core budget in the regional Library resource. The application describes an energetic and productive core staff operation moving in the areas of planning, support in identifying needs, assistance with project development and in evaluation of operational effectiveness. In addition, the application reports on some 20 feasibility studies conducted during the previous year, generated with assistance from the central staff, - but conducted by members of the program outside the core staff. Four of the five new projects included in this application stemmed either from planning or feasibility studies conducted with core funds. The structure of the Core staff is divided into the following categories: Office of the Program Director Medical Practice & Evaluation - includes an associate director and assistant directors for Oncology, Cardiology, Continuing Education and Evaluation Regionalization Services - includes an associate director and four Area Liaison Representatives Nursing and Allied Health Professions ~ includes a nurse who is an Assistant Director, a Nurse Specialist in Continuing Education, a Cancer Nurse and a Physical Therapist Communications - includes an Assistant Director, an Editorial Assistant and a Graphic Artist WESTERN PENNSYLVANIA RMP -12- RM 41-03 (AR-1-CD) Hospital Liaison - includes an Assistant Director and an Assistant Planner Fiscal Administration ~- includes an Assistant Director and-an Auditor Request Request Fourth Year Fifth Year $828,000 $908 ,000 Continuation Projects The Region requests continuation of the following seven projects. Five of them are moving into their third year of operation and two (#8 and #9) go into their second year. Requested Project #1 - Establishment of a Regional Postgraduate Faculty $35,450 of Medicine. © This project was supported last year at a level of $39,000. Continued support is requested to pursue the original objectives of: (1) to establish a faculty of community physicians in the Cambria-Somerset Area; (2) to’ improve postgraduate medical education in hospitals in that Area; (3) to assist each hospital medical staff to develop its own continuing education program; (4) to establish a communications link between the University of Pittsburgh research and educational resources and hospitals located through- out the Area; and (5) to facilitate exchange, for educational purposes, of physicians in the Cambria-Somerset Area and those at the University. Originally these efforts were directed toward the staffs of two hospitals and one County Medical Society. It expanded to serve three additional hospitals in Johnstown and in the upcoming year will extend to the Altoona area. The concept has been taken up by other Areas and the Region antici- pates that the Faculty ultimately can be supported by funds from. hospitals, hospital staffs, and professional societies which it serves. The project is entering its last year of RMP committed support. ; Requested Project #2 - Hypertension Management, University and Selected $97,500 Regional Hospitals This project was supported last year at a level of $88,000. Continued support is requested to pursue the original objectives of: (1) to inform practicing physicians about modern diagnostic and therapeutic methods for patients with hypertension; special emphasis is given to the diagnosis of surgically remediable hypertension and the medical management of essential hypertension; (2) to provide access to modern diagnostic techniques for patients with hypertension; (3) to identify leadership for the care of hypertensive patients in communities throughout the Region; (4) to learn the problems faced by community physicians treating hypertensive patients; and (5) to bring together a group of health professionals and health institutions to support the Regional Program. WESTERN PENNSYLVANIA RMP -13- RM 41-03 (AR-1-CD) Originally, eight hospitals participated in this project. It has proven popular and has been expanded to include nine additional hospitals. The application states some fees are generated from certain lab tests performed and the amounts collected are returned to the grant. The site visitors plan to inquire about these arrangements because the funds cannot be traced in the fiscal information presented. The participation in this project repre- sents good regionalization. The medical practice data already collected will be used to measure the project's impact of the educational program in terms of changing habits of medical practice for hypertensive patients. Also, a questionnaire is being developed to evaluate (1) the way most practicing physicians diagnose and manage hypertensive patients in the hospital and their offices and (2) the possibility of developing a pilot detection and treatment program in selected communities. The survey is to be initiated in January 1971 and future plans. hinge on the survey results. This project is entering its final year of RMP committed support. Requested Project #3 - Regional Program for Nurses in Coronary Care $118,486 This project was supported last year at a $106,700 level. Continued support is requested to pursue the original objective of enriching the knowledge and enhancing the skills of nurses caring for patients with acute myocardial infarction. A total of 257 nurses graduated in the first six courses and it is antici- pated that 200 more will be trained in the remaining four University courses scheduled for the last six months of this operational year. In addition, 19.nurses have been trained in the Clearfield satellite program and 18 in Johnstown. In all, the three programs have provided coronary nurses for 65 hospitals in 19 Western Pennsylvania Counties and two hospitals in Ohio. All of the courses have been filled to capacity. Evaluation of the training has shown that 80% of the 257 graduates plan to work in coronary and intensive care units as compared to 40% prior to the course and that training has resulted in both increased knowledge and improved performance. Although this project is entering its final year of RMP committed support, the information included in the application indicates the Region feels there is a continuing need for this type of activity in the Region's future plans. Requested Project #4 - Emergency Resuscitation Team Project. $26,875 This activity was supported last year at a $35,500 level. Continuation funds are requested to pursue the following objectives: (1) to train a team nucleus for individual hospitals; (2) to assist these hospitals to train other personnel in emergency resuscitation; (3) to train members of teaching teams for each Heart Association Chapter to provide for continuing education in emergency resuscitation; and (4) to help hospitals to evaluate the success of their team's efforts. WESTERN PENNSYLVANIA RMP -14- RM 41-03 (AR-1-CD) This activity is jointly sponsored by the Pennsylvania Heart Association and the University of Pittsburgh. The courses are held in Pittsburgh. Five courses have been held and five additional courses are planned during the remaining six months of this operational year. Twenty-four hospitals participated in the first five courses. Three of the remaining courses were ‘ fully subscribed when this application was prepared. At the end of this project, a survey of the Region's hospitals will be repeated to determine ' the number who have instituted full emergency resuscitation team programs as a result of this project. Requested Project #7 - Establishment of a Regional Medical Program Library $50,000 ‘System. This activity was supported aa similar level last year. The Region feels this project has met with considerable success in meeting the following objectives: (1) to strengthen local hospital libraries; (2) to promote cooperation among these libraries; (3) to disseminate information directly in response to requests for copies of individual articles; and (4) to provide information in response to requests for a search of the literature for information regarding a specific problem. Considerable statistical-use data is provided. Although strongly endorsing the continuation of this service, the Regional Advisory Committee recommended that support be sought from other community resources after its final RMP funding year. Hospitals will be expected to contribute as well as the Regional Medical Library in Philadelphia. Such support is likely to be inadequate and the Region's plans for the second and third year of the triennium are that this activity be , continued at a $30,000 level as a core activity. A total need for the expanded activity is estimated at $75,000. . Requested $75,000 Project #8 - Laurel Mountain Home Health Aide Project. This project was activated last year entirely through carryover funds at a $76,600 level. The activity was approved by Council for a three-year period and this application requests funds for the remaining two years. It is sponsored by the Community Nursing Service of Johnstown, Pennsylvania, Inc. The original objective was to make available to patients in a rural area of four counties (Bedford, Cambria, Clearfield and Somerset) adequate home health services where such services had not previously existed. Since the project was activated, the sponsors have expanded the geographic scope by opening a satellite agency in Glasgow, in the northeastern section of Cambria County. Later, the satellite was moved to a location more central to the service area. In November, another satellite was opened in Jennerstown, Somerset County. A hospital-based agency is scheduled for April 1971 in Bedford County. RMP funds are only used to pay expenses for the training of home. health aides. This activity was operational for only three months at the time the application was prepared. The Region plans to evaluate it on the basis of quality of care -and cost effectiveness. Approximately $38,000 was expected to be unexpended in this project's current budget. Second Year Request $80,000 WESTERN PENNSYLVANIA RMP -15- RM 41-03 (AR-1-CD) ; Requested Project #9 - Training of Cancer Chemotherapists for the Community $44,820 Hospital. This project was activated September 1, 1970 through rebudgeted funds at a $32,400 level. It seeks to provide training in Chemotherapy to six practi- tioners from the Region every six months through preceptor-directed clinical experiences over a six-month period on a one day per week basis. It is sponsored by the Western Pennsylvania Hospital Association and was begun with the establishment of an office in the Mellon Pavilion at Western Pennsylvania Hospital. Five students began their preceptorship program on November 1, 1970. In addition, a symposium on Cancer Chemotherapy was held in November attended by 42 physicians, 13 registered nurses, eight résidents, seven medical students and two interns. , It is planned that the preceptor group and the community chemotherapists will develop guidelines for the use of chemotherapy in the community hospitals of the Region. Evaluation in the future will include particular attention to the register of patients brought under treatment by the participating trainee physicians. In addition, the physician will provide, each quarter, a descrip- tion of the progress of patients under his care. Changes in referral patterns and the establishment of cancer teams will be identified. Six students were being recruited for the next preceptor program at the time the application was prepared. The Region expected no difficulty in filling the course. Full second and third years are requested with a partial fourth year to afford the activity three years of operation. Third Year Fourth Year . $46,995 $4,800 Renewal Project Requested Project #6R- Training of Nursing Home Personnel. $143 ,445 When this activity was originally submitted as part of the Region's initial operational application, three years of support were requested. However, Council approved it as a demonstration project for a period of two years. While there was no question that the training was aimed at filling a documented need, Council felt that relationships needed to be established between the referral agency, the hospital and the nursing home, and the curriculum neéded to be described. This activity was funded at levels of $125,000 and $137,500 for its first and second years. The application states that its objectives to be pursued in the two-year renewal period are: (1) to improve the quality of nursing service; (2) to improve the quality of administration; (3) to improve dis- charge planning procedures; and (4) to evaluate their own services. It will provide instruction by a multidisciplinary team over an eight-month period WESTERN PENNSYLVANIA RMP ~16- RM 41-03 (AR-1-CD) and follow-up for the following 12 months. Classroom instruction is ‘directed toward the administrator and at least one charge nurse from each participating nursing home. Classroom instruction is augmented by regularly scheduled visits to the homes. Up to now, thé didactic portions have been presented only in Pittsburgh. In the renewal period, similar programs will be presented outside Pittsburgh to So ( allow for involvement of more of the Region's nursing homes. Nineteen homes enrolled in the first course and 23 in the second. Approxi~ mately one-third of the extended care facilities in the Region have partici- pated in this project. As the project continues, the Region plans to focus increasingly on the © problem of adequate discharge planning. “Still to be developed is a mechanism to assist the exchange of patients between hospitals and nursing homes to reduce unnecessary hospitalization and to provide appropriate secondary care for nursing home patients whose condition deteriorates. Second Year Request $146,337 New Operational Projects 7 Requested Project #10 - Early Care for Suspected Coronary Patients. $37,424 This one year proposal revolves around the Region's highest priority objective. There are no other early care experiments in the Region although one presented formerly to the Regional Advisory Committee was rejected because of its reliance on telemetry and large numbers of in- completely trained personnel. , This mobile unit will operate out of Westmoreland Hospital located in Greensburg, a community of 17,800 persons, 35 miles east of Pittsburgh. It maintains 270 beds and serves a semi-rural population of 80,000. This hospital established one of the first coronary care units in the Region. It is served by a community ambulance service offering 24-hour service. Area residents recently presented the service with a fully equipped coronary care ambulance. The State Nurse Practice Act has recently been amended to permit this experi- ment. The project will study the cost and effectiveness and an early care system that generally follows traditional mobile procedures but provides for a decision by the coronary nurse whether the patient is to be evaluated in the emergency room or is to be taken directly to the coronary care unit. The November 1970 Council minutes include the following policy expression: 'obile Coronary Care Units: Experience with such units to date has demon- strated that initial costs are high and experience to date has not developed capability to predict the degree of success that can be expected for given combinations of organization, staff, equipment, population and to assure geographic coverage and regional cooperation. In subjective comparison, it seems likely that the sum required to demonstrate a mobile unit program would WESTERN PENNSYLVANIA RMP -l7- RM 41-03 (AR-1-CD) produce greater benefits if invested in a well-planned preventive program instead. Council asked RMPS to advise Regional Medical Programs to fund no new mobile coronary care projects." This proposal had been considered by the Regional Advisory Committee prior to the communication of Council's action. Requested Project #11 - A Regional Program for Patients with Sickle Cell $50,000 Anemia. This one-year proposal, sponsored by the University of Pittsburgh, is designed to assist the 189,000 members of the black community. It aims to: (1) improve the understanding in the black community of these diseases; (2) identify patients with sickle cell anemia and related hemoglobinopathies ; (3) develop a better understanding of the value of available methods for the medical. and social support of patients with hemoglobinopathy through innova~- tive medical and social care system; (4) provide continuing education for physicians caring for patients with sickle cell disease; (5) develop a facility to screen interested groups for sickle cell trait and to develop an understanding of the value of counseling for those found to have this genetic trait and (6) stimulate research aimed at correcting the consequences of inherited hemoglobin abnormalties. Health practitioners working with the black community have tried to organize -an effort for patients with sickle cell disease in Pittsburgh for over ten years. : Screening for sickle cell trait will be offered initially to employees of - the Health Center. Later, the screening will be extended to black children in selected schools. The second stage screening will not be undertaken until there has been an opportunity for parents to understand the intent. Counseling will be provided by members of the Sickle Cell Society. , The evaluation will be accomplished through seven mechanisms which, generally, include recording the number of educational devices developed, an opinion poll, changes in the use of medical facilities by patients, the number persons screened and the incidence rate, and the number of persons referred to the clinical research facility and the use of new treatments. Requested Project #12 ~ Regional Program for Patients with Diabetes $50,000 Mellitus. This two-year proposal aims to: (1) study the diagnostic and therapeutic practices used for hospitalized patients with diabetes; (2) provide a Regional consensus as to needed diagnosis and treatment programs; (3) identify for practicing physicians, their colleagues with a special interest in diabetes and endocrinology; and (4) strengthen the relationship between these physicians and those in the Region with similar interests in the Health Center teaching hospitals in Pittsburgh. WESTERN PENNSYLVANIA RMP -18- RM 41-03 (AR-1-CD) Pennsylvania is second among the 50 States in the reported mortality from diabetes mellitus. Six hospitals have indicated their willingness to participate in this project. Three of these hospitals are. in Johnstown, one in Indiana, and two in Pittsburgh. The two Pittsburgh hospitals will provide instructors. The project format provides for the review of existing ‘ records with a formal data collection instrument, monthly meetings for physicians to be held in each participating hospital with a panel of consultants, \ and visits by community physicians to the metabolic-endocriné unit of the Magee-Womens Hospital under direction of the Project Director. Evaluation will pursue. the number of physicians attending, hospitals partici- pating, records reviewed, educational opportunities identified, and programs - presented in response to these opportunities. To evaluate the effect of the project on the use of diagnostic techniques in the Region, the use of the . serum - insulin measurement in participating hospitals will be followed and evaluated in terms of Regional consensus as to the clinical value of this determination. ‘The cost of the determination also will be identified. Second Year Request $60,000 , , Requested . Project #13 - Bucktail Area Emphysema and Pulmonary Disease $42,115 Project. This is a two-year proposal to improve the care of patients with emphysema and other respiratory diseases. To accomplish this the project will: © oe (1) develop new inhalation therapy departments in five Area hospitals; (2) demonstrate the value of a screening program for chronic obstructive pulmonary disease; (3) establish a respiratory intensive care unit in one hospital to serve the Area; (4) provide continuing education on the diagnosis and treatment of pulmonary disease for Area health professionals; (5) stimulate a developing spirit of cooperation in the four-county Area; and (6) establish communication between health professionals and institutions in that Area with those in the rest of the Region. ‘The request for the project generated from the Bucktail Area Advisory Group some 15 months ago following 4 survey of each of the hospitals in the area. The project will serve a 3,000 square mile area of the northeastern part of the Region with a population of, 173,000 served by 118 physicians in general practice. There are seven hospitals in the area only two of which have established inhalation therapy programs. The proposal includes four components: Basic training for inhalation therapy technicians, screening, respiratory care units and continuing education. The | first component appears to be in conflict with RMPS policy on training of inhalation therapists and this point will be explored during the site visit. Reasonable evaluation methods have been described for each of the components. Second Year Request $34,378 ee PENNSYLVANIA RMP ~19- RM 41-03 (AR-1-CD) Requested Project #14 - Renal Disease. , $192,050 The original application for operational status from this Region included a three-year program for the treatment of kidney disease. The funds requested were in the neighborhood of $700,000 for each of the three years. It was an all~encompassing proposal and the April 1969 Review Committee concluded that it was rather ambitious and recommended that it be returned for revision to reflect primarily the training aspects, May 1969 Council concurred in this recommendation. This proposal, for a three-year program, represents the revised project. However, in the interim, RMPS Guidelines for Planning a Comprehensive Regional Kidney Disease Program, have been issued and preliminary review of this proposal raises questions as to whether the revised version complies. The site visit team will explore this situation and report on it to Committee. Second Year Request Third Year Request $275,165 . $350,486 RMPS /GRB 3/8/71 e-9 WESTERN PENNSYLVANIA REGIONAL MEDICAL PROGRAM - Area Adyisory Groups ‘ I (Crawford, Forest, Venango, Warren) II Bucktail III Lawner IV’ (Beaver, Butler) V Evergreen VI Southwest VII Westmoreland .~ VIII Laurel, Mountains “1X Appalachian-HighLands ” ALLEGHENY Pittsburgh We/RMP Area Advisory Groups Shared Relation- ship with Susque- hanna Valley RMP Affiliated with Western New York 2 RMP A PRIVILEGED COMMUNICATION a _ SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE. WESTERN PENNSYLVANIA REGIONAL MEDICAL PROGRAM RM 00041-03 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL Recommendation: Committee recommended that the Region be awarded $1,450,000 for each of three years including developmental component funds. The ad hoc panel recommended disapproval: of the revised kidney proposal, #14, on basis of technical merit. | Requested . Recommended Year Direct Costs Only __Direet Costs Only 03 $1,757,550 $1,450,000 04 $1,970,875 $1,450,000 05 $2,233,286 $1,450,000 TOTAL : $5,961,711 $4,350,000 Committee Program Critique: The recommendations of the March 10-11,. 1971 site visit team were considered and unanimously recommended for approval. The Committee was impressed with the strengths of the Western Pennsylvania RMP reported by the site visitors--the program momentum generated in its first 18 months of operational status, the regionalization of its structure (with nine active sub areas each with a’ strong local advisory committee) the demonstrated competency of the Core staff and its leadership, and a very knowledgeable and active Regional Advisory Committee. It: was the consensus of the reviewers that the Region had proposed a viable three-year plan of growth. The Committee agreed that the goals, objectives and priorities evidenced good strategic planning and that the progress reported by the ongoing activities warrant continued support. The new operational activities proposed for the first year of the triennium. were judged to be faithful extensions of the Region's goals and objectives. However, in view of the negative findings of the ad hoc panel with respect to the revised kidney proposal, project #14, Renal Disease was recommended for disapproval. Also, project #10, Early Care for Suspected Coronary Patients, and those aspects of project #13, Bucktail Area Emphysema and Pulmonary Disease, that concern the basic. training of jnhalation therapists, were not recommended for approval in view of Council's policy. With respect to project #10 the Committee noted that coronary care is the Region's highest priority; that the feasibility study preceding this proposal began in 1969; and that the proposal was approved by the Regional Advisory Committee prior to the enunciation of Council's policy with respect to such experiments. The Review Committee agreed that the Western Pennsylvania RMP had convincingly demonstrated the capability to receive developmental component funds. The well-judged use of program funds last year for planning, feasibility studies, WESTERN PENNSYLVANIA RMP -2- | RM 41-03 - ne” 4 and seed money, coupled with the types of investments described as developmental opportunities for the triennium were considered in arriving at this recommendation. The reviewers endorsed the very favorable impressions of the site visitors with respect to the Core staff role in this Region, its demonstrated competence, and. its excellent leadership. Committee agreed that an increase in the level of Core support was warranted. The site visitors had recommended, and the Committee agreed, that the Region's review process meets the requirements for decentralization. The process involves collaborative efforts of staff with the proposer, technical consultants from categorical committees, task forces and area advisory groups, on-site review by members of the Operational Grant Review Committee and technical consultation from within or outside the Region. The area-wide CHP agency in the southwestern part of the Region is afforded opportunity to comment. The Committee approached the "unspecified growth funds" request cautiously. The concept of a region operating within a broadly described triennial plan without referral to Committee/Council for specific project approval at such times as new activities are implemented was not fully discussed. While the Committee approved the level of funding recommended by the site visit team (which provides "growth funding") Committee did so with the understanding that those activities now only generally described but planned for implementa-— tion later in the Region's triennium, will be submitted through the review : process for specific evaluation. The recommended level of support developed by the site visit team and recommended for approval by the Committee was arrived at in the following manner: Core support $ 650,000 Developmental Component 100 ,000 Operational Activities (continuing, renewal and new) 700,000 $1,450,000 No funds for projects #10 or #14 were included in these amounts. Also, the reduction of funds for project #13 is reflected in the above computations. Panel Technical Critique: With respect to project #14, Renal Disease, which is a revision of a previously submitted proposal, the Panel recommended disapproval. While there would seem’ to be adequate pro- fessional staffing to conduct the project in most respects, there were grave doubts as to their harmonious relations and commitments. Although the million dollars earmarked for kidney disease activities from the State of Pennsylvania has not yet been apportioned, this proposal lacks the element of coordination with other RMPs in the State. The reviewers felt that training periods of two and three weeks were too short to be of real value. The relationships of the @ vere: are not well worked out. ~ RMPS/GRB 4/22/71 =. = PML LIND UA ae eas } . DEPARTMENT OF HEALTH, EDUCATION, AND nep ene - PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION toMareh 19, 1971 | Reply to Atin of: y Subject: Quick Report on Western Pennsylvania Site Visit ~ March 10-11, 1971 To: Acting Director. Regional Medical Programs Service a) “ mun, THROUGH: Acting Deputy Director pees Regional Medical. Programs Service . The team was composed of the following members: Leonard Scherlis, M.D., Chairman, Professor of Medicine and Chief, Department of Cardiology, University of Maryland Hospital Franklin G. Ebaugh, M.D., Dean, College of Medicine University Medical Center, University of Utah John A. Mitchell, M.D., Deputy Director, California Committee on Regional. Medical Programs . Edith V. Olson, R.N., Nursing Coordinator, Rochester Regional Medical Program Frederic Westervelt, M.D., Assistant Professor of Internal Medicine, ‘ University of Virginia Medical School Gerald Gardell,. Chief, Grants Management Branch Rebecca Sadin, Continuing. Education Branch Loretta Brown, Planning and Evaluation Branch James Smith, Regional Development Branch Lorraine Kyttle, Grants Review Branch Glyde Couchman, Regional Representative Rodney C. Mercker, Grants Management Branch Briefly, the visitors came away.with concerns in some areas, but with the Unanimous impression that we had visited an energetic, effective Region. The dreas of concern are: This is a provider-oriented program that deeply feels the politicizing of héalth: care programs is the business of CHP -- it sees this as the y i Page 2 - Acting Director, RMPS natural division between the two programs. It candidly attributes its progress to its provider base. Agreement was reached to expand its representative structure to include the social groups it serves. The visitors believe that many of the general responsibilities and specific assurances vested with most grantees have been delegated in this Region to such an extent that the grantee may be a paper organization. The areas of strength: A tremendously energetic Core staff, bound together by unusual espirt de corps and competence. An involved and knowledgeable Regional Advisory Committee that listens to and works well with its Local Advisory Committees. The Chairman is a real plus. The talent of attracting the time and attention of University faculty with strong action and community-oriented bents. These are volunteers and are not on the RMP payroll. The knack of identifying local resources and good local leadership. Western Pennsylvania's terrain makes travel difficult, particularly during the winter, and even with a very stringent "attend or be dropped" rule, Local Advisory Committees and Regional Advisory Committee involve- ment is very good. A highly qualified group of nurses, deeply committed to the program both at the local level and particularly the Dean of the School of Nursing. The skillful use of feasibility studies and seed money to address new priorities. Funding Recommendations: Present Level Requested Levels Recommended $1,248,391 03 yr. - $1,757,550 . $1,450,000 ($ 226,350 is 04 yr. ~ $1,970,875 $1,450,000 carryover from 05 yr. - $2,233,286 $1,450,000 the 01 year) In arriving at a recommended level, the consultants computed the full amount for a Developmental Component, funds for some expansion of Core staff, and a revolving account for operational activities in the neigh- borhood of $700,000 which must support both ongoing and new activities for the full triennium. No funds were included for the kidney disease proposal; for the mobile coronary care proposal; or for the basic training of Inhalation Therapists, - Page 3 - Acting Director, RMPS ©@ 8 The consultants also recommend that the Region be authorized to use up , to 10% of its FY 71 $863,996 level for Developmental Component purposes and that the local RMP review process meets the minimum requirements for decentralization. , 4 , Cc np liit Wy 2 Keggetle- ‘ : ‘Lorraine M. Kyttle _. Program Analyst Grants Review Branch A Privileged Communication SITE VISIT REPORT WESTERN PENNSYLVANIA REGIONAL MEDICAL PROGRAM March 10-11, 1971 SITE VISITORS Leonard Scherlis, M.D., Chairman, Professor of Medicine and Chief, Department of Cardiology, University of Maryland Hospital Franklin G. Ebaugh, M.D., Consultant, Dean, College of Medicine, University Medical Center, University of Utah John A. Mitchell, M.D., Consultant, Deputy Director, California Committee on Regional Medical Programs Edith V. Olson, R.N., Consultant, Nursing Coordinator, Rochester Regional Medical Program , Frederic Westervelt, M.D., Consultant, Assistant Professor of Internal Medicine, University of Virginia Medical School REGIONAL MEDICAL PROGRAMS SERVICE STAFF Gerald Gardell, Chief, Grants Management Branch Rebecca Sadin, Continuing Education Branch Loretta Brown, Planning and Evaluation Branch James Smith, Regional Development Branch Lorraine Kyttle, Grants Review Branch Clyde Couchman, Regional Office Representative Rodney Mercker, Grants Management Branch WESTERN PENNSYLVANIA REGIONAL MEDICAL PROGRAM STAFF F.S. Cheever, M.D., Coordinator, WP/RMP; Vice~Chancellor, Health Professions, University of Pittsburgh Robert R. Carpenter, M.D., Director, WP/RMP Enid Goldberg, Ph.D., R.N., Assistant Director for Nursing and Allied Health H.J. Simmons, III, Assistant Director for Hospital Liaison David E. Reed, M.D., Assistant Director, Evaluation and Medical Practice George P. Sartiano, M.D., Assistant Director for Oncology Ruth N. Mrozek, R.N., Nurse Specialist in Oncology REPRESENTATIVES OF WESTERN PENNSYLVANIA REGION James A. Rock, M.D., Chairman, WP/RMP Advisory Committee, Department of Pathology, Lee Hospital Kenneth D. Rogers, M.D., Chairman, Department of Community Medicine, University of Pittsburgh WESTERN PENNSYLVANIA RMP -2- . RM 00041 Harry K. Wilcox, Vice-Chairman, WP/RMP Advisory Committee; Administrator, Westmoreland Hospital Jack D. Myers, M.D., University Professor, School of Medicine, University of Pittsburgh School of Medicine Constance Settlemyer, Assistant Project Director Catherine M. Brosky, Project Director « Lawrence F. Blackburn, M.D., Westmoreland Hospital Raul Mercado, Jr., M.D., Department of Radiology, Presbytéerian-University Hospital Donald Cohen, M.D., Pathologist, Sharon General Hospital Dane R. Boggs, M.D., Department of Hematology, University of Pittsburgh School of Medicine , Nathaniel Murray, President, Sickle Cell Soclety James A. Stewart, Jr., M.D., Director of Ambulatory Care, Mercy Hospital of Pittsburgh Donald N. Medéaris, Jr., M.D., Dean, School of. Medicine, University of Pittsburgh — Mrs. Hattie Hickman, Staff, Pittsburgh Model Cities Agency Thomas W. McCreary, III, Rochester General Hospital Lee H. Lacey, Executive Vice-President, Harmarville Rehabilitation Center Mrs. Maude H. Malick, OTR, Director, Occupational Therapy, Harmarville Rehabilitation Center Daniel E. Leb, M.D., Director, Renal Therapy Unit, Presbuterian-University Hospital — Edward F. McCrossin, Jr., Secretary, WP/RMP Advisory Committee; Executive Director, Hospital Council of Western Pennsylvania , Marguerite J. Schaefer, Dean, School of Nursing, University of Pittsburgh David W. Clare, M.D., Chairman, WP/RMP Cancer Committee . John G. McCormick, Chairman, WP/RMP Community Involvement Committee; Associate Executive Director, Health and Welfare Association of Allegheny County Dan J. Macer, Chairman, WP/RMP Bylaws Committee;'‘Assistant Vice-Chancellor, Health Professions, University of Pittsburgh Edward H. Noroian, Chairman, WP/RMP Nominations Committee; Executive Director, Presbyterian-University Hospital J.E. Ricketts, M.D., Chairman, WP/RMP Stroke Committee; Medical Director, Harmarville Rehabilitation Center Waldo L. Treuting, M.D., Chairman, Board of Directors, Western Pennsylvania Comprehensive Health Planning Agency; Professor and Head of Department of Public Health Practice, Graduate School of Public Health, University of Pittsburgh . ‘ Frank M. Mateer, M.D., West Penn Hospital, Pittsburgh, Pennsylvania t WESTERN PENNSYLVANTA RMP -3- RM 00041 INTRODUCTION The site visit was in response to an application from the Western Pennsylvania Regional Medical Program proposing a three-year plan of action and growth. Under the Anniversary Review and Award System, the WP/RMP had no options to submit applications during its second operational year. The request submitted for this review cycle reflects the Region's decision to submit a triennial application on its anniversary rather than an application geared only to its plan for the next year. In addition to displaying the specific activities to be continued and new activities to be initiated in the upcoming year, the application described new thrusts presently in the planning stage which are scheduled for activa~ tion in the second and third years of the triennium. The purposes of the site visit were to assess the Region's overall progress, its current quality, its prospects for the next three years, and to arrive at a funding recommendation based on the intrinsic quality of the program. ORGANIZATION OF THE REGION James A. Rock, M.D., Department of Pathology, Lee Hospital, Johnstown, Pennsylvania and Chairman of the Regional Advisory Committee, and F.S. Cheever, M.D., Vice-Chancellor, Health Professions, University of Pitts- burgh and Coordinator, Western Pennsylvania RMP opened the meeting with a short resume of the Organization of the Western Pennsylvania RMP. When. the « legislation on regional medical programs was passed, Dr. Cheever gathered approximately 50 medical and hospital leaders in Western Pennsylvania who decided to develop a planning grant application. The University Health Center of Pittsburgh was agreed on as the grantee. This is a corporation originally composed of four and now comprising five large hospitals affiliated with the University for teaching, training and research. Once the planning and initial organizational effort was accomplished, the Region experienced difficulty in getting off the ground until Dr. Carpenter was appointed Program Director. In response to a request for more detail on the Cheever vis a vis Carpenter relationship, Dr. Cheever replied that Dr. Carpenter as Program Director "does everything" and that he (Cheever) serves in a supplementary role, principally as the link between the RMP and the University. Dr. Carpenter volunteered that he values Dr. Cheever's relationship not only to the Board of Trustees but to other segments of the community RMP serves. Dr. Cheever had mentioned certain distrusts in the medical community concerning RMP in its formulative stages. Dr. Rock, in responding to a site visit team question regarding that point, feels RMP afforded the first real forum in” which some of these distrusts could be dispelled. In Dr. Rock's view, the combination of Dr. Cheever's link with the University and Dr. Carpenter's method of operating with medical communities in the Region are very valuable attributes and contribute heavily to the RMP's success. During this discussion, the team learned of the existence of a "Coordinator's Staff Conference." This group, which is not shown in the Region's organiza- tional structure chart in the application, is composed of some six or seven members. It meets with Dr. Cheever every fortnight or when it has business WESTERN PENNSYLVANIA RMP ~4- RM 00041 to discuss. At this time, its members include Dr. Carpenter, Dr. Rock, Dr. Medearis, Mr. Macer, Dr. Cheever, Dr. Rogers, Dr. Leonard and Dr. Johns. Dr. Cheever described it as a mechanism to exchange information with no legal responsibilities or accountability. Dr. Rock was asked if this means the WP/RMP operated on two levels. He replied that Dr. Cheever guides rather than pushes--that the RAC is quite open in its deliberations with no problem regarding the Coordinator's Staff Conference--RAC has never felt they were constrained by either Dr. Cheever or the grantee--the Board of Trustees had never vetoed a RAC action. The site visit team met privately with Dr. Carpenter the next morning to discuss several points one of which was the rationale of continuing the organizational structure whereby Dr. Cheever is designated Coordinator (with a "Staff Conference" mechanism) and Dr. Carpenter is - Director of the program. Dr. Carpenter stated that the current arrangement is acceptable to him; that it affords him the opportunity to relate to the medical community in Allegheny County in the different manner that is required; that he would not want to work in a regional medical program without strong University ties; that to operate differently. in reaching the community would possibly be to have the program under CHP; that he believes we are feeling the pressures to politicize the program. 14 After discussing the role of. the University Health Center of Pittsburgh as the grantee, the team concluded that many of the general responsibilities and specific assurances vested with most grantees seem to have been delegated by the Center to the extent that the grantee may be a paper corporation. Dr. Donald N. Medearis, Jr., Dean of the School of Medicine, University of Pittsburgh, described the Relationship of the Health Center and the RMP. He said the school has the pleasure and the obligation to participate. Because he views continuing education as becoming oriented towards "career renewal" he sees the University playing a larger role in that field and that Medical School/RMP relationships will increase. The expansion of the cate- gorical emphasis to primary and comprehensive health care will, he feels, help this relationship. o OBJECTIVES AND PRIORITIES Dr. Kenneth D. Rogers, Chairman of the Department of Community Medicine, and one of the original WP/RMP proponents, spoke about Setting Objectives and Priorities. Dr. Rogers said that their firstefforts were to fund activities that they felt were visible, high impact projects. The Region was struggling with its own objectives which had not been defined nationally. The RAC estab- lished a task force (composed of RAC members plus other providers in the community) which developed objectives based on "best practices." Through evolution they found that staff, project proposers, and RAC's ideas were beginning to jell and that they were more comprehensive than they had originally thought. When the objectives were charted, the grid began to fill in and yet it provided for innovation. Mr. Harry Wilcox, Vice-Chairman of the RAC and Administrator, Westmoreland Hospital, Greensburg, Pennsylvania spoke on Management by Objectives. He said objectives were the result of strategic planning. This includes regional allocation of resources and upward and downward movement of ideas. WESTERN PENNSYLVANIA RMP -5- RM 00041 Dr. Jack D. Myers, Professor, School of Medicine, spoke on Protecting The Innovator. In addition to the structured system, Dr. Myers has championed the need for a person with a different idea to have access through the system. He feels seed money should be available for innovative opportunities and feels RMP has displayed good vision in this area. Dr. Rock covered the Ordering of Priorities and in his opening remarks alluded to his interest in how RMPS set its priorities with $70 million. A planning conference attended by 250 volunteers attempted to establish priorities. Group dynamics and discussion in the sub areas and Area Advisory Groups with input from staff as well as budget restrictions all contributed to the ordering of priorities. Staff brings these from the LAC to the RAC and RAS refings. The present plan was begun as a tentative plan; was found to be workable and is now called the current plan; it will be revised constantly as requirements dictate. National priorities were identified as one measure for a revision requirement. Dr. Carpenter described the Role of Staff in setting objectives and priorities. He placed staff in the role of the change agent, sensitive to national priorities. He stated that the RAC did not always buy staff's ideas on priority ordering, and gave primary care as an example. Of some 50 sub- objectives developed almost two years ago, 15 are implemented, 14 are underway, nine have been dropped (unproven health care objectives) nine are stalled and three are being developed at this time. Sharp questioning followed these presentations concerning what the site visitors perceived as an almost exclusively provider-oriented system. Dr. Rock stated he feels RMP/CHP are the two most important agents in Western Pennsyl- vania for impact on health care delivery. He feels that RMP should be provider-oriented because it asks providers already working in the delivery system for voluntary efforts to change and improve that system. He sees the provider-oriented base of WP/RMP as a natural division between CHP and RMP. He conceded that CHP in some parts of Western Pennsylvania is still formulative, thereby giving the consumer no real voice. Dr. Rock also is a member of the CHP Council. Dr. Rogers stated that the stance We/RMP took allayed the appre- hension of the medical community who realized they would not be overwhelmed by other forces. He feels that the term "provider-oriented" should be more clearly restated as based on need and realities rather than on consumer demand. It was, he said, the provider's perception of need that led them to the "best practices" concept. Dr. Carpenter stated that within their best practices concept built on need, the RAC has rejected more proposals than it has approved and that the rejections were based on both poor technical quality as well as low priority need for the Region. EVOLUTION OF PROJECTS AND FEASIBILITY STUDIES Dr. Alvin Shapiro described the ongoing Hypertension Management project which is entering its last year of RMP committed support. The knowledge gained through this effort hopefully will result in future funding through the community hospitals and NIH. Dr. Rock identified Dr. Shapiro as an early University self-starter who saw RMP as a valuable community link. In addition to the small RMP investment Dr. Shapiro had garnered a great deal of University manpower and money for the project. WESTERN PENNSYLVANIA RMP -6- RM 00041 Dr. Enid Goldberg described the ongoing Coronary Care Nurses project which enters its final year of RMP support. The Region feels it is a highly successful program. Dr. Carpenter stated that in their order of priorities partial support from RMP is possible but it will probably fall below a silat support base, Miss Catherine Brosky discussed the ongoing Regional Library System and Dr. Carpenter outlined his plans to obtain future partial support for this activity through hospitals (by charge) and the National Library of Medicine. . Next the team learned about the effect of feasibility studies. Mr. Wilcox and Dr. Lawrence Blackburn both of Westmoreland Hospital traced the opportunity, through the responsiveness of RMP, to develop a study of earlycoronary care in Westmoreland County. The study was initiated July 1969. The County was the first Area in the Region with a coronary care unit and the topic in the medical community is transportation of the coronary patient. Two proposals emerged-~-one was rejected by the RAC and one approved. The latter is included in the present application. RMP contributed less than 50% of the’ total cost. The area advisory group zeroed in on a mobile coronary care unit rather than equipping a conventional emergency vehicle to reduce variables and increase evaluation benefits. Drs. Raul Mercado, George Sartiano and Donald Cohen, discussed the value of feasibility studies conducted with partial RMP support in the cancer prograr: area. They described the thin distribution of resources outside the Pitts- : burgh area and as a result of the study decided to develop continuing educa~ tion programs based in local hospitals. One of the valuable spin offs of the study is. that radiologists are now willing to send their patients for radio- therapy consultation to the Center. Dr. Dane Boggs, Mr. Nathaniel Murray and Dr. James Stewart discussed how the sickle cell project evolved from a feasibility study started a year ago. As part of a survey, it was found that seven out of eleven people in the Allegheny County area did not. know what sickle cell disease was. 70% of tne Region's Black community lives in Allegheny County. The group has developed | a public awareness plan of what can be done for people suffering from the disease. A Sickle Cell Society has been formed and a: screening program is on the books. The group also has worked thru the Allegheny County School system with enthusiastic acceptance. The University of Pittsburgh has launched a research program and is merging with other research efforts in the country. Realizing that not all of the Black community would receive hospital care in areas that are acutely aware of the disease, the society is sponsoring a program beamed at the staffs of those hospitals to make them more aware of the disease and the trait. They are also working on the emergency room problem. Screening and genetic counselling are items to be pursued under the operational flan. Dr. Carpenter summed up this portion by saying that generally, feasibility studies fall into two categories: Those that pre-study the plan for a project and those that build on existing data from the Hospital Utilization Plan system. The Western Pennsylvania RMP is a participant in HUP. WESTERN PENNSYLVANIA RMP -]- RM 00041 David Reed, M.D., Assistant Director for Evaluation and Medical Practice, WP/RMP, told the team about the Region's Use of Evaluation and Planning Data. The Region participates in the Harvard Information Support System which uses a broad sociologic program approach. They believe the inputs from the system are helpful but in their view the study needs a stratafied listing of persons aware of health care problems. In addition to Dr. Reed's core staff activities, evaluation has built on other small segments and efforts not qualifying as feasibility studies or projects. The Region had developed a standard quarterly reporting format for project directors supplying data sheets and anecdotal information. The Region is collecting measures of behaviorial and attitudinal change and is tackling the total sociological measurement which they described as a tough challenge. As an example of one effort to evaluate a facet of total program impact, the Region is measuring the man hours of University personnel spent directly in or with the community, measuring the Region's 01 year against its current 02 year. The opportunity to review the medical practice records of many of the Region's hospitals had been successfully courted and Drs. Carpenter, Reed and Rogers are engaged in that effort with assistance of medical students. WHERE THE REGION IS GOING Mr. Edward McCrossin, Jr., Director of the Hospital Council of Western Pennsylvania and Secretary of the RAC discussed the Effectiveness and Future Role of the Program. Mr. McCrossin is also Chairman of the RAC's Operational Grant Review Committee. He said it was very difficult to interconnect the Region. The terrain has resulted in hospitals built on local bases. The Region has never before been served or surveyed on a regional basis by any active planning group. (Mr. McCrossin's emphasis). The Region's hospitals are terribly obsolete. He thinks RMP has fielded a well balanced program and is delighted with the uniqueness of the program not being structured on the basis of population or State lines. Within his experience, he has found no other program that could transport planning into action in areas with essential hostilities to any other area or large city the way Western Pennsylvania RMP has. He would never have believed two years ago that a small community hospital would give its records to a planning body for audit of medical care rendered. Mr. McCrossin feels strongly that RMP is the first agent in the area that has demonstrated the ability to coordinate and that if the CHP has the effect of review and comment authority "they had better have the expertise to do it." Dr. Carpenter then led a discussion of Projects Proposed in the Current Plan. On the subject of Primary Care he was joined by Marguerite Schaefer, Dean of the School of Nursing, Mrs. Hattie Hickman of Model Cities Agency and Mr. H.J. Simmons, Assistant Director for Hospital Liaison, Western Pennsylvania staff. Dr. Carpenter started the discussion by stating that primary care is different things in different parts of the Region. Some of it takes the form of psycho- social support. He feels they can go so far in primary care planning but do not have the resources for the primary care involved. RMP representatives, the Vice-Chancellor and union representatives met recently to develop guide- lines for an HMO. The Model Cities representative described the plight of the WESTERN PENNSYLVANIA RMP -8- RM 00041 Pittsburgh area. There seems to controversy over the number of hospital beds needed and over the question of renovating existing antiquated facilities versus building. They hope RMP can help with planning assistance. The Region's proposed referral project, still in planning stage, is -endorsed and needed. Dean $chaefer described the proposed pediatric nurse practitioner program and its future contribution to comprehensive primary care. She said it stemmed from an RMP based limited feasibility study the summer before. It * began as an experiment with ten trainees. She already sees things that will be changed the next time around. The next step is the medical nurse practi- a tioner. She feels the combination_of the pediatric and medi cti-..... tioner will make a real impact. She plans to modify the curriculum of the preprofessional students in nursing so that four years hence graduates will be prepared to practice-in the specialty practice of ambulatory health. care. . She states she will have no trouble filling 100 slots -~- the experiment was: twice subscribed without recruitment. The VNA director is retiring and they are now recruiting her replacement. She sees the possibility of a combination VNA-PH nurse... There is no in-house setting where family practise, tioner experience can be gained. , Mr. Thomas W. McCreary of Rochester General Hospital, Beaver County, Pennsylvania and Ruth N. Mrozek, R.N., WP/RMP staff spoke about the Region's developing plans for nursing support of the community hospital cancer care team. Miss Mrozek is a graduate of the Master's degree program for cancer nurse specialistaattthe Pittsburgh School of Nursing. The cancer. care team activity is receiving support from local Cancer Societies and with comple- menting RMP funds is scheduled for operation in Mid 1971. It is estimated. that 70-80% of the requirdd support should be self-generated after the first - year of its operation. Mr. Lee Lacey, Executive Vice President of the Harmarville Rehabilitation Center, Harmarville, Pennsylvania, and Mrs. Maude Malick, OTR, also >f the Center described the plans for a rehabilitation mobile training and.demonstra- tion activity for MD's RN's, PT's, OT's and supportive personnel, The vehicle is still in the design stage -- one of its uses is to complement the RMP ongoing nursing homes project. Four areas with an estimated 3,000 paralysis patients are being studied. There are no rehabilitation facilities in the areas other than a County Home and a VA hospital. Local hospitals are identifying discharged patients requiring rehabilitation. Of the five specified new activities to be implemented in the first year of the Region's triennium, only the revised kidney disease project was subjected to an in depth review. Dr. Westervelt met separately with Dr. Leb, the proposed acting project director, and Dr. Westervelt's comments have been forwarded to the ad hoc technical panel meeting today on kidney disease proposals. Dr. Westervelt's conclusions were that the proposal could not be supported in its present form but that a little "developmental money" could help this potentially capable (if better organized) group get this project going. WESTERN PENNSYLVANIA RMP -9~ RM 00041 @ The Executive Committee jointly discussed the Strategy for Developmental Component which covered the areas of the value of the feasibility activity; the review mechanism for a developmental component and the effect of limited funds on program development. The following is an abbreviation of their collective statements: . The Executive Committee meets monthly and is composed of all the Chairmen of the special committees plus the Chairman of the RAC, 9 a Vice Chairman (Mr. Wilcox), a Secretary (Mr. McCrossin who is also Chairman of the Operating Grant Review Committee) and Dr. Cheever. . So much of what has been done in the past was through the Developmental Component concept funded with carryover that if no developmental funding is permitted, it will have a drastic effect on the program. . They are deeply concerned over how much real autonomy will be permitted. . They have a constituency of approximately 460 involved providers and they feel the full RAC has demonstrated tremendous commitment. Even with the Region's terrain which makes travel difficult, a very stringent "attend or be dropped" rule resulted in the loss of only six out of 48 members. Replacements are being considered. . RAC has had to make decisions before, based not only on quality and © need, but on funding restraints and they can do it again. . Retrenched funding will require the consideration of re-ordering priorities which will begin with Staff consultation with local advisory groups, a proposal developed by the Executive Committee , and presentation to the full RAC for discussion. . They feel the program as it is presently constituted has a level below which it cannot operate and significantly retrenched funding will require the scrapping of a highly successful concept. . The existing review procedures will apply for developmental component proposals with latitude delegated to the Program Director to act independently in cases combining a request for less than $10,000 for a duration 'of less than 12 months. Periodic post reporting to the RAC is required. Waldo Trueting, M.D., Chairman of the Board of Directors, Western Pennsyl- vania Comprehensive Health Planning Agency and Professor and Head of the Department of Public Health Practice, University of Pittsburgh, was joined by Mr. Dan J. Macer, Assistant Vice-Chancellor, Health Professions and Chairman of the RMP-CHP Task Force in a discussion of the Relation of RMP and CHP. CHP in Western Pennsylvania became operational in December 1969. Dr. Trueting said RMP was instrumental in getting them started. They had no money while RMP had both dollars and interest. Mr. Macer was instrumental in interesting representatives from 31 counties in Western Pennsylvania and wwe - : awe tet ag OMe a . an Fo Callan oe WESTERN PENNSYLVANIA RMP .~ ~10- RM: 00041 * Southeast Ohio as well as the West Virginia panhandle. The final proposal - covered 12 counties in Southwéstern Pennsylvania in forming six sub-area Councils. Of 69 members of the area Council, 37 are consumers. The B agency formed went directly to an operational status. There is overlapping RMP-CHP membership on the board at the A level. Mr. Macer is the Chairman. Dr. Rock is another overlapping member. CHP in Western Pennsylvania does x not consider itself a master planning agency--it feels its role is to stimulate and coordinate the planning of agencies. The B agency has no a regulatory authority. Other,B. agencies are being planned, but other thdit — t the two that have been forméd, no others exist at this time. THE CONCLUSIONS OF THE CONSULTANTS The visitors came away with concerns in some areas, but with the unanimous impression that they had visited an energetic, effective region. The areas of concern are: This is a provider-oriented program that deeply feels the politicizing of health care programs is the business of CHP -- it sees this as the natural division between the two programs. It candidly attributes its progress to. its provider.base. Agreement was reached to expand its representative structure to include the social groups it serves. The visitors believe that many of the general responsibilities and specific assurances vested with most grantees have been delegated in this region to such an extent that the. grantee may be a paper organization. The areas of strength: A tremendously energetic Core staff, bound together by unusual espirt de corps and competence. , An involved and knowledgeable Regional Advisory Committee that listens to and works well with its Local Advisory Committees. The Chairman is a real plus. The talent of attracting the time and attention of University faculty with strong action and community-oriented bents. These are volunteers and are not on the RMP payroll. , The knack of identifying local resources and good local leadership. Western Pennsylvania's terrain makes travel difficult, particularly during the winter, and even with a very stringent "attend or be dropped” rule, Local Advisory Committees and Regional Advisory Committee involvement is very good. ° A highly qualified group of nurses, including the Dean of the School of Nursing, who are deeply committed to the program. The skillful use of feasibility studies and seed money to address new priorities. ioe ‘. v WESTERN PENNSYLVANIA RMP ~ll- * BM 00041 Generally, the organizational structure is good, with reservations about the Coordinator/Director arrangement. The ongoing operational projects are making excellent progress, considering the fact that the Region is only in its second operational year and twa activities are in their first year. The Region's progress in the area of project and program evaluation is very good and its new approaches to total impact measurement are excellent. The local review process meets the requirements for decentralization. The Region has demonstrated the capability to receive developmental component funds. The goals and objectives are clearly stated and well aligned to the Region's. operational approaches. The decision-making bodies that developed them also developed mechanisms for priority re-ordering. Improvement could be made here by interfacing goals and objectives with total program targets--that is, to first state the changes in health care delivery the program hopes to effect in addition to stating the methodology the Region intends to pursue. FUNDING RECOMMENDATIONS: Present Level Requested Levels Recommended $1,248,391 03 yr. - $1,757,550 $1,450,000 ($ 226,350 is 04 yr. - $1,970,875 $1,450,000 carryover from 05 yr. - $2,233,286 $1,450,000 the 01 year) In arriving at a recommended level, the consultants computed the full amount for a Developmental Component, funds for some expansion of Core staff, and a revolving account for operational activities in the neighborhood of $700,000 which must support both ongoing and new activities for the full triennium. Based on Dr. Westervelt's findings after consulting with the proposers of the kidney disease project, no funds were included for that activity. The proposal will be reviewed by an ad hoc panel April 14-15th for submission to May 1971 Council. Also, in view of Council's statements regarding the funding of mobile coronary untts, no funds were included for the proposed Early Coronary Care project. Funds were also deleted for that portion of the Bucktail Area Emphysema and Pulmonary Disease Project which covers the basic training of Inhalation Therapists. Following the feedback session, Dr. Rock thanked the visitors for sharing their views with the Region and asked that as part of a two way communication, the team relay the following message from the Region: The deeply involved manpower in the Region constitutes a valuable constituency and yet they are frustrated by changing leadership | at the Federal level and by their inability to understand the _ rationale of constantly shifting "rules." If they are to be of real value, RMPS simply must get away from the "carrot and stick" basis of operation. WESTERN PENNSYLVANLA RMP eg RM 0008 During the past year, it has teen extremely "difficalt to successfully relay to their very strong area groups who have deep commitments to the program that limited funding simply does not permit them to do many of the things they know need to be done. Dr. Rock acknowledged this as only his second meeting with Mr. Couchman Y and his first contact with Mr. Smith. He asked that RMPS representatives ' "meet with us when we meet" as the only real way they will understand the Region. i . oof ay ‘ . .