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BACKGROUND MATERIALS FOR SPECIAL MEETING OF
REPRESENTATIVES OF HEALTH SERVICES AND
MENTAL HEALTH ADMINISTRATION AND

REGIONAL MEDICAL PROGRAMS

Airlie House
Warrenton, Virginia
August 21-22, 1959

The attached statement of DRAFT PRINCIPLES FOR HEALTH PROGRAMS
SUPPORTED BY THE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION was
prepared within the Health Services and Mental Health Administration
for discussion purposes only by a small group consisting of program
directors and other senior staff. Its purpose was to permit consideration
of what guiding and coordinating strategy might be followed by the Health
Services and Mental Health Administration and its program constituents,
including Comprehensive Health Planning, Hill-Burton, National Institute
of Mental Health, and Regional Me“ical Prograns Service.

 

 

The paper wes designed only to provide a basis on which to test eee
ideas and engender discussion, and does not reflect the conclusions of: /
that group. It should also be noted that this paper was not intended

for general distribution and, as such, is classified as ADMINISTRATIVE,

CONFIDENTIAL. 5 06

In reviewing this statement there are two specific points that
should be kept in mind

. The inference that might be drawn from the section cn
page 7 ("The activities of regional medical programs
at the community level should be carried out under the
auspices of the area-wide comprehensive health pianning
agency") was not meant to suggest that Regional Medical
Programs would te administratively under or subordinate
to such an agency, but rather that a Regional Medical
Program would be a professional arm to the area health
planning agency and that its activities would need to
be closely coordinated with those groups at the
community level.

. The emphasis on the specialized nature of Re
Medical Programs in the statement does nct 4
take into account the much broader role that
already has and might increasingly ox t
particularly as it relates to stren

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as well as specialized care capabilities.

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ADMINISTRATIVE CONFIDENTIAL

DRAFT PRINCIPLES
FOR
HEALTH PROGRAMS SUPPORTED
BY THE,

HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION

I. Purpose

The purpose of these guidelines is to assist communities in making
the most effective use of sources of Federal support for improving
the organization and delivery of health services within the community.
These Federal programs have come into being as a response to perceived
inadequacies in the organization and delivery of health services -—
inadequacies which are reflected in problens of distribution, cost,

_ and quality of health services. While the Federal Government has
responded to these needs by making available support, the extent to
which programs will achieve their objectives is Largely dependent on
the effectiveness of implementation at the community level. The

_ essential role of the Federal Government, with the assistance of the
States, is to help community resources to develop more effective
systems of health services. The Federal programs discussed below
represent a variety of flexible mechanisms which can be utilized to

'

meet community needs. ‘These guidelines are intended to assist in

that process.

II. Scope
These guidelines specifically deal with the coordination of health

programs supported by the Health Services and Mental Heaith Administration,
 

although the coordinating approach is relevant to other Federal programs

supporting health services. The primary HSMHA programs which will assist
communities in improving the organization and delivery of health services
are Comprehensive Health Planning at the statewide and ateavide level.
Regional Medical Programs, Community Mental Health Centers and related
activities in alcoholism and narcotic and drug abuse, project grants for
the establishment of primary ambulatory care programs, project grants

for maternal and child health services, and Hill-Burton construction
grants for health facilities.

Detailed guidelines for each of these programs are attached. The
summary guidelines are intended to assist communities in putting together
a package of Federal support which has maximum impact on the health
services problems of the community. To the community, these programs
represent programmatic tools, each designed to fit an important part of
the community's machinery for developing improved health and mental health
services, each with sufficient flexibility to enable the community, to

build a coherent strategy for making maximum use of each program's contribution.

III. Definition of Community

“There can be no fixed definition of community for purposes of
effective organization of health services. The "community of solution" for
putting together the many facets of effective systems of health care ser~
vices should encompass a wide enough area so that only rare cases would
need to be referred outside of the community for specialized services.
The community should encompass those elements of the health system that

interact on a regular basis. In most situations this concept of
community will match the coverage of the areawide comprehensive health
planning agency. This broad community may have subunits for specific
purposes, such as a neighborhood health. program, the catchment area of
a community mental health center, or the natural service area of a
community hospital. But the community must be broad enough to encourage
and permit effective coordination of services rather than contribute to
further fragmentation. |

With the great variety of local circumstances, there can be no fixed
model of geographic or population coverage which would serve the purposes
of effective program coordination. We will work with each community,
however, to encourage a coherent pattern of geographic coverage for the
various programs support through the HSMHA funds. The geographic coverage
of an areawide planning agency’ should consider the mental health catchment
areas, any subregions of the regional medical program, hospital service
patterns, and other economic and local planning considerations. Attention
to the geographic scope of the community health plans can facilitate

effective program packaging and coordination.

IV. The Role of the State

It is an objective of HSMHA policy te encourage an effective state
role in health programs. The state carries out many important functions
in the health arena; and for many health activities at the community
level, the state is an integral part of the “community of solution."
For the state as for the Federal Government, the focal point for the
organization of services is at the community level, and HSMHA's support

to the state strengthens the state's capability to assist communities
in achieving the objective of more effective organization of services.

This support is provided through formula grants to state health de-
partments for the support of public health services and through the |
support of state comprehensive health planning. The primary purpose
of health planning at the state level is to assist the governor and
the various state agencies with roles in health activities to carry out
their ‘responsibilities more effectively through studies, analysis,
advice, and assistance in the area of health-affairs. In addition to
providing assistance on specific responsibilities of state government
in health, the state health planning agency can provide oversight from
the governor's perspective on the activities of community health
planning agencies and other health institutions and organizations,
public and private, whose activities have an impact on state responsi-

bilities in health.

V. Scope of the Areawide Comprehensive Health Planning Agency

HSMHA will encourage the development of the areawide comprehensive
health planning agency as the fundamental instrument for integrating the
impact of health programs on the needs of the community. The areawide
“agency should carry out this responsibility as a part of its evolving
role as the focus for community responsibility in health affairs. With
the community mandate deriving from its broadly representative advisory
re this agericy's concern should include the distribution of services
within the community, the efficient use of health resources, including
a concern for the costs of medical care, and a purview over the effec-

tiveness and quality of services. The agency is also in a position to
highlight the health impact of environment factors and to advise and
assist those agencies with operational responsibilities in the environ-
mental area on the health implications of their responsibilities.

The areawide agency should have the following responsibilities:

-- identifying and analyzing community health care problems, providing
information and analysis on health needs and resources

~~ analyzing the costs and effects of alternative courses of action
in meeting health needs

-~- serving as the convener agency for bringing together representatives
of various elements of the health care system to work on specific problems
or programmatic developments

-- serving as a mechanism for the expression of consumer concerns

about health care problems, such as accessibility and cost of services

and for the expression of community priorities and health

—- monitoring the efficiency and effectiveness of the health care
systems within the community

-- serving as the stimulator and developer of appropriate joint
management responsibilities for elements of the health care system,
including the possible development of nonprofit management corporations
for health activities ,

-- assisting community health resources in the effective packaging
of Federal support to meet community needs.

The areawide planning agency can serve as the umbrella for committees
concerned with specific aspects of community health, such as ‘mental health,
environmental health, utilization review, and implementation of advanced

technology and knowledge in improving the health care system.
VI. Capital Financing

The areawide comprehensive health planning agency should review and
comment on all proposed construction of health facilities which would
utilize Federal funds, including those provided through Medicare, \
Medicaid, and the Maternal and Child Health Programs. HSMHA will
encourage agencies responsible for funding decisions on capital con-
struction to weigh heavily the comments of the areawide agency in making
those decisions. In reviewing state plans for Hill-Burton, HSMHA will
give important consideration to the role assigned to areawide planning,
the extent to which plans for construction of facilities are matched with
careful analyses of health services needs within the community, and the -
impact of that construction on encouraging the use of less expensive
services and efficient utilization of highly specialized services. In
reviewing plans for the construction of community mental health centers,

review and comment by the areawide planning agency will be required.

VII. Comprehensive Primary Care

HSMHA policy encourages the development of comprehensive family-centered
primary care at the neighborhood level. Community health plans should
specifically include an approach to providing comprehensive primary care
with priority for lower economic groups. Since all available evidence
indicates that comprehensive primary care, including effective preventive
and community outreach services, will reduce the utilization of more
expensive health services as well as increase the effectiveness of health °
services for the population group served, the community's plans for

developing systems of health services that meet the needs of the entire

population should lay out an approach to more effective organization of
pima——"
e

-~~ primary services and the development of specific relationships between

primary services and higher levels of care. The use of HSMHA sources of

‘support for developing primary services through project grants for
- health services and maternal and child health project grants should be
.-linked with community plans for the development of other aspects of
““health services through other HSMHA programs. HSMHA will provide technical

: assistance to communities in the development of plans for these relationships.

VIIL. Regional Medical Programs

The regional medical programs are intended to insure that advances in

medical knowledge are made more widely available and are introduced into

the health care systems in an effective and efficient manner. The activ-

, ities of the regional medical program at the community level should be
. carried out under the auspices of the areawide comprehensive health planning

agency. The areawide agency could turn to the regional medical program

for the following assistance and support:

-- the provision of technical assistance and consultation on the

application of advanced technology to medical care, as well as support

- for selected projects that involve cooperative arrangements among a

number of elements of the health care system.

-- the provision of assistance, consultation, and support concerning

improvements in the substance of health care, including the organization
‘

and support of programs of continuing education.

-~ organization and support for specialized training activities
meeting the needs of the community or region, RMP serving as a broker

between the institutions utilizing health care personnel and institutions

providing training.
 

 

~- development under the RMP of highly specialized health care
capabilities and the establishment of regular referral patterns with the
community for the efficient use of these capabilities; development of
the specialized capabilities should be coordinated with the general health
care planning undertaken by the areawide planning agency.

in carrying out these functions, the RMP can utilize the capabilities
of major teaching institutions of the region and can serve as the bridge
between this expert capability and the needs of the community. The
specialized assistance provided through the RMP can be applicable to all

levels of health resources within the community.

IX. Community Mental Health Centers

- The community mental health centers provide an important element
of the health care system of the community. The areawide health planning
agency should play a role in establishing relationships and referral
patterns between the community mental health centers and other health
care resources. These organized patterns of relationships should make
possible an effective division of function between the development of
comprehensive primary care, including some aspects of mental health
services and more specfalized mental health capabilities provided by the
community mental health centers. These relationships, however, would

’

not exclude direct or self-referral to community mental health centers

for those in need of mental health services.

X. Technical Assistance to Communities
Assistance in the interpretation and implementation of these

guidelines will be provided to communities through the regional offices