Regional Medical Programs Service Statement of Mission and Functions Purpose . The purpose of this statement is to define and delineate the mission of the Regional Medical Programs Service. The statement is designed to provide broad guidelines to the several elements of RMPS in formulating the nature and direction of their program efforts. At the same time, it defines an integrated mission ‘for RMPS which supports and promotes the major objectives and concerns of the Health Services and Mental Health Administration. Mission of RMPS The central mission of RMPS is to strengthen and improve the patient care system in order that the. quality of care (including its availability and accessibility) received by individuals may constantly be improved and the capacity of the system (including its effective- ness and ef ficiency) may be enhanced. To carry out this long-range mission, RMPS presently has avail- able to it two major program mechanisms : (1) Regional Medical Programs for Heart Disease, Cancer, and Stroke as authorized by Title IX of the ” PHS Act and (2) the categorical health care. programe which rest upon the broad authority of Section 301 of the PHS Act. The first is directed toward enhancing the capabilities of providers of patient care by foster- ing regional cooperative arrangements. Grants are made for the estab- lishment and operation of Regional Medical Programs aimed at improving care for patients with heart disease, cancer, stroke, ‘or related diseases. Equal emphasis is given to prevention and rehabilitation as to acute care. The second program mechanism provides technical assistance and development in several major categories of health care. Its focus is primarily on the development of capability for preventing illnesses which have long-term disabling consequences. Regional Medical Programs - Title IX Regional Medical Programs is establishing a process of regional- ization by which research, training and demonstrations of patient care -3- are undertaken.’ It represents an effort to upgrade the capabilities of the health providers, which when taken together, will help improve the quality of and accessibility to comprehensive health care for the total population. The enhancing of capabilities and the establishing of regional cooperative arrangements are viewed as "equal" and mutually reinforc- ing objectives. They represent a dual approach that may be illustrated as follows: a Improved Patient Care aw Demonstrations of Regionalization of Improved Health a Health Resources Designed Services to Improve the System and A . , Combat Fragmentation a (Projects) Ts - (Program) A strong tendency exists to focus upon demonstration projects as a direct route to improved patient care. However, given the size’ of the total health demand, demonstration projects can only affect a very small percentage of the population. What is needed is to insure a systematic approach to the improvement of the patient care. Emphasis on improving the overall management of the system as well as quality of individual patient care must become the primary focus of Regional Medical Programs. Regionalization of health resources is seen as one important means to this end. Demonstration projects, even when they -~-4&- clearly result in improved patient care, are supportable through RMP only insofar as they strengthen cooperative arrangements significantly. While this criterion has increasingly been the "style" of Regional Medical Programs, it must now be made its "substance" also. The highest priority in awarding grant funds must be given to projects and activities that establish or strengthen relationships be- tween and among the various elements of the system (e.g. medical schools, teaching hospitals, community hospitals, physicians). These elements must be pulled together to become mutually supportive if the ‘project is to have any substantial impact. For unless this is an ‘integral part of each RMP- supported project or activity, the projects may very well increase rather than overcome the existing fragmentation that plagues our patient care system. Service The dual focus of Regional Medical Programs ,must be reflected in the organizational structure and process at the Federal, the regional, and local level. Without an appreciation of the mission of RMPS, the tendency will be to create grantor-type organization~-a "little NIHY-- which may do little to enhance systematic approaches to care. What is required is the creation of an organization responsive to the com- munity and its health needs. It must have a continuing planning capa- bility and process, and a decision-making mechanism which addresses itself to the major health problems and issues as well as to the substantive and technical merit of individual proposals. Given this basic framework of program direction, a number of priorities emerge which can be used to guide the review mechanism and funding process. If the program is to promote activities it has ~ 5 ~ defined as having the highest priority, it must do so through the manner in which it awards funds as well as through the issuing of policy statements. . All operational projects must implement significant coopera~ tive arrangements which contribute to a more systematic approach to improving patient care. . We have demonstrated our capacity for developing improved technology but have lagged in our application of these improvements to certain groups of our society. Emphasis must therefore be placed on improved application of our knowledge to all citizens. . We must constantly seek. to strengthen resources at the community level. . Account should be taken of the extent to which local cost sharing will help establish local priorities and stimulate community interest. . Communities should be assisted to secure proposals which funds from reflect,other Federal programs as well as from RMPS. _ . if better balance is to be achieved between ambulatory care (including prevention) and acute inpatient care, funding policies should favor the former. , Health Care Development ~ Section 301 The categorical health care programs of Regional Medical Programs Service will become deeply involved in a redirection of effort to provide technical assistance and capability to the 55 Regional Medical Programs and to the planning activities of the Service. It is recognized that -6- this redirection will come at a significant loss of accomplishment in technical development, and although top priority will be given to needs defined at the regional level or projects looking ‘ward ways of overcoming technical barriers to (or stréngthening) coopera~ tive arrangements, it must not become an exclusive requirement. ;To pursue such a shortsighted policy would result in a staff competent to advise only gn yestetyear'e advances, -The role of technical assistance to the regions and to RMPS involves a number of components which can be identified as separate units but which in actual practice will probably intermesh: (1) One function will be to provide to the Director of RMPS information relevant to new health systems and subsystems including recent manpower innovations, technological developments, and new methods of organizing health care. The implications for the health care system in regard to the categoric fields and to systematic approaches to comprehensive care would be provided. E.s., cost benefit studies relating to the adoption of new methodology might lead to improved priority setting for RMPS, both in the grant and contract programs. (2) A second function, the categorical health care programs will be available to assist individual Regional Medical Programs in the design and development of projects. As this activity uncovers regional needs and demands for new technical development, the staff would undertake, with the resources available to RMPS, to overcome technical and behavioral barriers to widespread adoption of improved methods of care. 7. (3) A third function will be to provide technical review for the project proposals from the regions. (4) Another function will be the development of a technical evaluation capability of new advances and care subsystems. For example, a limited number of mobile coronary care units have been funded on an experimental basis. Coordinated evaluation of these units could provide feedback to the RMPS and to the National Advisory Council as to the feasibility of such projects (units) and the extent to which they should be supported elsewhere. : Priorities in Regional Medical Programs Service activities (as seen from the view of the staff of the categorical programs that com-~ prised the old NCCDC) include the following: - Projects and activities which emphasize early intervention in the disease process, This would mean encouraging projects _with preventive aspects and those with an emphasis on primary care. | | . Activities which provide wider distribution and better utili- zation of existing advances, especially as these relate to disadvantaged populations. . Activities which emphasize improving the overall management of the patient care health system. . Within. the role of providing assistance to the regions, an increased emphasis on social and organizational competence as well as technical competence. Some of the major barriers to successful regional programs are a lack of capability in organizational dynamics and developing systems as often as ~8- a lack of technical or medical capability. In those developmental projects which are undertaken, an emphasis on those which could be widely adopted at a low cost, on those which will affect large numbers of people, and those with the potential of success over the near future. Issues and Implications This proposed statement of mission while it is essentially program- matic in its thrust, does have a number of implications or pose issues for the administration, management, and organization of RMPS. Among these are: 1. Need for national review process, including site visits, to be more au courant, and to reflect program priorities. Manner of requesting and allocating contract funds. Will RMPS be the point of control? Division of contract funds, and grant funds also to the extent that the Section 910 authority is so utilized, for technical development between national needs and regional demands. Degree of flexibility in reprogramming current DCDP/DRMP contract funds. ; Organizational structuring and placement of the technical assistance and deve lopment function. Presently this exists in both DRMP and DCDP, with the former having a functional orientation (e.g., continuing education) while the latter are disease oriented (e.g., heart and stroke, cancer). ef 10. -9- In terms of RMPS staff, the greatest resources would be devoted to technical assistance and development regard~ less of how this function might be structured. To what extent will the sheer magnitude of the technical assistance and development function, and its strong cate~ ,gorical orientation, contribute to the very thing we seek to avoid--a primary focus on demonstration projects? How is the program balance being sought to be achieved? One aspect of this is the previously mentioned need for including social and organizational capability in the assis- tance program as well as technical capability. Relationship and relevance of the DCDP field stations to the new technical assistance and development model? Role of the RMP Review Committee and Council with respect to contract-funded technical development activities? Necessity of broadening the categorical disease technical. assistance and development function in the event Regional Medical Programs was "decategorized" in its extension.