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UNIFED STATES GOVERNMENT DEPARTMENT OF HEALSIL, EDUCATION, AND WELFARE
Vie ra ‘ ' PUBLIC HEALTH SERVICE
£hy? f
VECINOVARAUM

‘0 : Philip R. Lee, M.D., Assistant Secretary DATE: March 1, 1968
for Health and Scientific Affairs

’

ROM : Associate Director, NIH, and Director
‘Division of Regional Medical Programs

UBJECT: Regional Medical Programs~-An Investment in Improved Health Care--Fiscal
Years 1969-1973

_This memorandum augments the memorandum sent to you on February 16, 1962,
which analyzed the projected need for Regional Medical vrogram grant funds
through fiscal year 1973 on the basis of estimated net aggregate demand.

In this memorandum we would like to set forth the objectives of Regional
Medical Programs, the rationale for those objectives, and the outputs which
are relevant to evaluating the progress toward the objectives. We have
structured this document to a large extent in terms of the concept of the
Planning, Programming, and Budgeting Systems. It is our view that this
discussion of objectives justifies the investment of Federal funds pro-
-~jected in the February 16 memorandum.

Ultimate Objectives

D ‘"" The Surgeon General's Report to the President and the Congress on, Regional
Medical Programs states the goal of the Regional Medical Programs is
". . . clear and unequivocal. The focus is on the patient. Tne object
is co influence the present arrangements for health services in a manner
that will permit the best modern medical care for heart diseasc, cancer,
_ stroke, and related diseases to be available to all." The ultimate
achievement of Regional Medical Programs, therefore, has to be measured
"in terms of end-product outputs, such as changes in morbidity and mor-
tality in these disease fields, and the impact on the quality of life.
However, measuring such ultimate outputs is considered by most leading
experts to be very difficult and, in most cases, impossible in terms of
relating specific end results to specific inputs. ,

For example, the death rate for discases of the heart declined three,

per cent for the period of January-November 1967 according to the National
Center for Health Statistics. Deaths from strokes dropped 2'3 per cent
during the same period while deaths from cancer rose three per cent, Yet
it would be very misleading to attribute any part of these changes to the
initial activities of Regional Medical Programs. The Division of Regional
Medical Programs is supporting studies to improve the capability of the
Regional Medical Programs to evaluate activities in terms of effects on
the health status of people. Several papers presented at the recent

Sere : - | HELP ELIMINATE WASTE COST REDUCTION PROGRAM

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Regional Medical Programs Conference-Workshop described such studies.
But such end-product analysis is not yet developed to the point where
it is useful either for projections for the next five years or for’
analysis of the effects of those initial investments during the five-
year period. Furthermore, progress in reducing mortality from one
chronic disease may have the overall effect of increasing the inci-~

’ dence of another ailment.

Interim Objectives

Because end-product analysis is not useful for our immediate purpose
.of reasonable projections of investment in Regional Medical Programs,
we must adopt working hypotheses or assumptions. These assumptions
serve as interim objectives for action and are valid bases for eval-
uating the progress of the program on an interim basis. We fully
realize that these working hypotheses need to be tested as the program
develops and modified as improved techniques and tools are developed
for defining more precisely the effects of program activities.

Most of the major assumptions and constraints, which serve as the
“current basis for the development of Regional Medical Programs, are
found in the authorizing legislation and the legislative history

which led to the establishment of this program. These assumptions

and constraints are relevant to this discussion of why a sizable
investment of Federal funds for these purposes is justifiable at this
time and why we can posit that the significant return on the marginal
Federal dollar invested in this program at this time justifies increased
investment during the next five years.

PL 89-239 assumes that a gap exists between the type of health services
this society is capable of making available in these disease arcas and
the actual availability of such services to large segments of the popu=-
lation. The gap may be in terms of access to services or in terms of

the quality of the services being provided. This gap may be widened
in the coming years due to the continued advance of medical science
unless specific action is taken to close the gap. Many different ecle-
ments are relevant to closing the gaps and the mix of these elements
is different for different areas of the Nation and for the various
problems that comprise the gap. Therefore, these programs are to be
developed on a regional basis with the flexibility in the national
guidelines to permit each region to develop programs based on their
particular needs and resources. .

Many different types of activity are relevant to closing the gap.
between our current health system and the availability of high quality

 
care to all. Major clements are stated in the law:

1) Research and development into better means for making the
advances of medical seience more readily available to the population In
need of these bencfits;

2) Training, including continuing cducation, which can help close
acute gaps in manpower, create new types of manpower for evolving health
functions, retrain existing manpower for the changes of function brought
about by advances in knowledge, and can upgrade the quality of existing
manpower as it is currently utilized in the health system;

3) Demonstrations of patient care, which serve to integrate into
the total system improved techniques and mechanisms for prevention,
diagnosis, treatment and rehazilitation, which provide the means for
extensive involvement of our health manpower and institutions in the
process of improving health care capability. ,

Most importantly, the law makes clear that these activities are to be
considered part of, and contributors to, the evolution of a system which
establishes and strengthens, on a regional basis, functional relationships
awong the elements of the health system. The law assumes that cooperation
of all cssential elements of the health resources in a region is an essen~
tial means of coping with the complexities of specialization, high cost,

‘©’. manpower needs, and educational training needs which are the by-products

of the dynamic advances of medical science. In overcoming the fragmenta~
tion and insularity of health resources, it is desirable to establish a
continuing relationship with the research and teaching environment of

the medical center, the patient care activities involving the community
hospital and practicing physician, and other health organizations and
agencies. The law assumes that only through such regional arrangements
can the health status of the patient benefit fully from the accompLlish-

’ ments of medical science. . *

The assumptions include major constraints. First, the development of
the programs is constrained by limitations of manpower resources and by
the availability of strong and imaginative leadership. Overall manpower
limitations and, in some cases, shortages of physical space for new
activities, demand the development of solutions to the target problems
within these resource constraints.

Another vital constraint is the necessity of moderating the rise in
medical care costs. The sharp rise in costs requires that means be
found’ to accomplish improvements in health care capability with exten-
give attention to moderating the increased cost of the improvements,
including the utilization of the advances of medical science and tech-
nology to provide superior care at equal or reduced cost.
Another significant constraint provided in the law is the development of
Regional Medical Programs through a voluntary cooperative approach. ‘The
Regional Medical Programs may stimulate and foster improvements in the
health care system and establish terms and conditions for participation
in activities of Regional Medical Progvams, but the programs may not
coeree existing institutions and activities into conformance with tae
Regional Medical Programs. ;

A final major constraint is the lack of a basis of experience and know-
ledge which can guide the developments of Regional Medical Programs.

The scarcity of existing relevant models calls for the application of

the experimental approach to the development of Regional Medical Programs.

The Process of Regionalization

Dr. Lester Breslow, in a talk at the recent Conference-Workshop, said,
M9 those concerned with the improvement of health care in this country,

' xegicnalization has become the order of the day." In the revised

Guidelines for Regional Medical Programs we ave chosen to describe the
&

overall mechanism for achieving the goal of Regional Medical Programs as

a process of regionalization. This process encompasses the development
of the activities described above on a regional basis and reviews those
activities in a framework where they contribute to an improved organiza~

 

‘tion and delivery system on a regional basis. Excerpts from the revised
_Guidelines describing the major elements of this process are attached to

this memorandum (see Attachment I).

The Primary Output Measure - Improving the Organization and Quality of
Health Care

The progress of Regional Medical Programs during the next five years can
propexly be measured on the basis of the assumptions which are explicit
and implicit in the authorizing legislation. The primary output measure

becomes therefore the extent to which the Regional Medical Program is

achieving the functional process of regionalization that can be expected
to improve the organization and quality of health care, There are some
difficulties in developing precise uniform measures of organizational
changes or modifications in the attitudes and behavior of health insti-

‘tutions, organizations, and practitioners; yet progress in modifying the

attitudes of the participants in the health endeavor should have a very
great impact on the improved efficiency and effectiveness of the total
health care system, The emergence of new patterns of attitudes and
relationships in the health field assumes very major importance when it

is realized that significant improvements in tue organization and delivery
of health services within the constraint of minimum coercive power are to

 
D L285

a large degree dependent upon modification of present attitudes and
patterns of relationships. Solutions co many of the particular
problens of closing the gap between potcntial and practice depend upon
a rericsil approach that effectively utilizes many elements of the °
health care system, and requires patterns of organization of heaith
care resources that make efficient utilization of expensive capital
facilities, scarce: manpower, or realize the full potential of the new
technology. Because a regional medical program provides the framework
for such a process of regionalization, it is appropriate that the
primary output be measured in terms of improved organization and delivery
of health services.

‘During this period of time overall progress is being measured in terms
of improved organization and delivery of health services, the individual
regional medical programs and the Division are devoting considcrable
effort to the development of better tools for the measurement of the
effects of program activities in end-product terms, such as changes in
morbidity, mortality, or other measures of health status, and the
application of these tools to the activities of regional medical programs..
(See Attachment IL for some examples of these cfforts.) While improved
_measuring techniques are being developed and their application tested,
the evaluation processes are already underway in regional medical programs.
These program evaluations in terms of improvements in the quality of
-.. health care will continue to rest, to a large degree, on criteria
8 : established through the consensus of best professional judgment. Such
criteria will, of course, be applicable to individual activities within
the regional medical program, and will not constitute a common index of
effect by which the total progress of the regional medical program can
be measured. ,

Additional Outputs

- The stimulation of improvements in the organization of health services
_,,does not, however, totally encompass the valid output measures of the
effects of regional medical programs.. These outputs result from the
planning and implementation of the individual regional medical programs,
and the specific activities undertaken by any regional medical program
-will vary in composition and amount from region to region. Therefore,
as the programs emerge into the operational phase, it will be possible
to describe these additional outputs with increasing specificity.
Exanples in the following categorics can be identified at this time (see
Attachment II for a fuller description of examples actually occurring
in regional medical programs):

1) Some of the activities of the regional medical programs may be

defined as research and development in health services, These research
and development activities may be in different methods of organizing
ee 6

health resources, in the development and testing in actual community
use new diagnostic and treatment techniques previously confined to the
laboratory environment, research and development in the technique of
evaluation of medical care, research into improved techniques for
education and training in the health professions, cost-benefit analyses,
and the development of new technologies that can moderate increased
medical costs,

2) The training activities of regional medical programs will
result in outputs which can be measured in terms of additional numbers
and improved effectiveness of health manpowcr. These outputs caa
include the development of new types of health manpower, the filling
of »axticular manpower gaps, and the improved effectiveness of existing
-heaith manpower through programs of continuing education. These
activities justify a considerable level of investment because the improved
effectiveness of health manpower should logically increase the efficiency
of the health care system as given inputs of manpower resources result in
greater outputs measured in end-product terms.

4

3) Demonstrations of patient care in regional medical programs
generate outputs in terms of the delivery of health services and the
prevention and control of discase.
All of these additional outputs are occurring and will occur within
Regional Medical Programs, but these additional outputs will take place
within an action framework that influenccs the improved organization
and delivery of health services. Therefore, the multiple outputs will
have a synergistic effect in terms of improved health care.

r

Factors Affecting the Level of Investment

In order to make a decision concerning an appropriate level of investment
in these programs a number of factors should be examined:

1) All elements of the health system are relevant to the purposes
of the Regional Medical Programs. in order to achieve the purposes, the
impact of RMP activities has to be felt at numerous points in the system
with extensive involvements in the activities of the programs. The mage
nitude of this task can be seen in the numbers of elements that should
be affected by the programs, including the 5700 gencral hospitals, 100
medical schools, 285,000 practicing physicians, 640,000 nurses and many
other health organizations and institutions. Since the total stream of
activity is so great, any activity intended to bring about modifications
and improvements in the total system requires sufficient extra funds to
accomplish these modifications. In order for any effects to be seen or
measured this basic investment level must be considerable, and an invest~

‘ment below this minimum level might be substantially wasted since the
opportunity to demonstrate the validity of the assumptions on which these
Bee

So a

programs are based would be lost. It is not likely that there is a
direct proportional relationship between investment and return util
this eritical mass’ of initial funding is exceeded. In Launching these
new programs the initial investments must be considered as risk capital
with a considerable potential payoff. ‘The extent to which the invest-
ment achieves its expectations can only be given a full evaluation if
the initial capital is sufficient.

2) The return on the funds invested to date scems to be consider-
able ia terms of the preliminary informed judgments that the Regional

‘Medical Programs have prospects for making significant progress toward

their goals. This was the conclusion of the Surgeon General's Report
to the President and the Congress and the conclusion is strengthened
‘by the recent Conference-Workshop on Regional Medical Prograns. _ The
initial return justifies additional investment, especially gince much
of the initial progress has taken place in anticipation of that further
investment. There is evidence that the return of marginal dollars
invested in these purposes continues to be high when measured by the
achievement of interim objectives. . ,

3) The costs of the various types of activities that are , being
_undertaken in Regional Medical Programs provides some indication of
“the magnitude of expenditures that are required for such activities

as: the organizational infrastructure of the Regional Medical ‘Program

including the planning and evaluation capability as well as systems

for the gathering,and analysis of,data on the health care system;

educational activities which must’ reach nearly all of the current pool

of health manpower; demonstrations of patient care that are sufficiently

distributed geographically and are supported at a level that can catalyze

improvements in the total health care systems; and the development and
exploration of new means for organizing health care and for utilizing

new technologies. It should be stressed that these types of activities

are unlikely to be supported at a sufficient Level to accomplish these

, purposes within the existing organizational, institutional, and finan-

cing frameworks of the health care system. Therefore, these purposes

can only be achieved by some additional investment external to.the

current sources of financing of health care.

'

Cone lusion

There are two approaches that can reasonably be adopted to determine
the actual amount of initial investment that will generate significant
progress towards the goals of Regional Medical Programs within the next
five years. ,

The estimated net aggregate demand of the Regional Medical Programs,
as. outlined in the memorandum on February 16, is an appropriate basis
for investment decisions in the initial stages of this pzogran, These
demands are generated through a regional process that is determining
regional goals and priorities and which take into consideration the
various resource constraints within che regions. Until experience is
gained and evaluated this estimated demand, after careful review and
evaluation by the review process at the national level, might constitute
the most reasonable estimate of the investment needed to provide a basis
for determining whether a program based on these assumptions can -achieve

its goals.

Since this program has many experimental aspects and since previous
models do not provide much information on which to base investment
decisions, it is also reasonable to view the projected investment for
the next five years as a level of effort based on a proportion of the
‘funding for the total health care system which this investment is in-
tended to influence. This initial level of effort could be viewed as
the investment necessary to make productive change, cspecially for
accomplishing improved quality and distribution of care. If the cotal
national investment in health by 1973 is running at a level in excess
of 60 billion dollars per year, the effects of investment through
Regional Medical Programs should be measured in terms of improvements
in the system, not just in terms of units of activity purchased with
the funds. As an initial level-of-effort investment decision, the
proposed authorizations through fiscal yei.c 1973 constitute less .than
1 per cent of the total annual national expenditures on health.

Therefore, we believe that the estimates provided in the memorandum

of February 16 are a reasonable basis tor projecting the investment
in Regional Medical Programs at this time.

Lf oe

Robert Q. Marston, M.D.

_Attachments
context of Regional Medical Programs has several other important

u

CHAPTER TL 0

 

ae bas

THLE NATURE AND POTENTIAL OF REGIONAL MEDICAL PROGRASS

 

GOAT, - YMPROVED PATIENT CARY - ’

Chapter I places the Goal of Regional Medical Programs in its
historical context and gives a fuller perspective to Seetion 966 o7
the Act (see Appendix I), which defines the Goal in dotail. In avbre=
Viated form, the Coal is described in the Surgeon Geneval's Ronors as
" ysclear and unequivocal. The focus is on the patient. Whe obfuct
is to influence the present arrangements for health services in 4 manner
that will pemnit the best in modern medical care for heart discase,

cancer, stroke, and related diseases to be available to ali.”

MEANS = THE PROCESS OF REGIONALTIZATION

Note: Regionalization can connote more

than a regional cooperative arrangement, :
- but for the purpose of Guidelines, the
‘ two terms will be used interchangeably.
The Act uses "vegional cooperative
arvangement," but "regionalization" has
become a more convenicnt synonyn. |

i

A regional cooperative arrangement among the full array of available

“health resources is a necessary step in bringing the penetits of scientific

advances in medicine to people wherever they live in a Region they
themselves have defined. It enables paticuts to benefit from the

“inevitable specialization and division of labor which accompany the

expansion of medical knowledge because it provides a system of worsen
relationships among health personnel and the institutions and organi
zations in which they work. ‘This requires a commitment of individual.
and institutional spirit and resources which must be worked out by eac
Regional Medical Program. It is facilitated by voluntary agreements to
serve, systematically, the needs of the public as regards the categorical
diseases on a vegional rather than some more narrow basis.

te
cae

Regionalization, or a regional cooperative arrangement, within
facets:
» it is both functional and geographic in

‘character. Yunetionally, regionalization

DRAFT ne
 

fie

Ae :
. y

is the mechanism for linking patiant
. eave with healih research and education

within the entire vegion to provida a

mutually benefiedal interaction. ‘this

{nteraction should occuc within the

operational activities as well as in the

total program. The geopraphic boundaries
~ of a region serve to define the population , “
for which each regional program will be
concerned and responsible. This concern . a '
and responsibility should be matched by
responsiveness, which is effected by
providing the population with a ougnisic
cant voice in the regional program's no
decision-making process.

. It provides a means for sharing limited

, “health wanpower and Facilities Co maxi-

mize the quality and quantity ‘of care
and service available to the region'

population, and to do this as cconomicaily
as possible. ‘In some instances, this may
require inter-regions% cooperation between
two ox among several regional programs.

. Finally, it also constitutes a mechanism
for coordinating its categorical program
with other health programs in the regioa - ' |
go that their combined cffect may be oi

“sy increased and so that they contribute to
4 ‘the creation and maintenance of a system '
i of comprehensive health care within the

entire region. 1

1

 

it is not the intent of a Regional Medical Program grant to supplant
either Federal or non-Federal sources of support Zor vartious activitics
related to achicving its purpose. Rather, tha Regional Medical Progra
provides an opportunity to introduce activities which draw upon and
eifectively link activities already supported, or supportable in the
future, through other sources. Current examples of otner Federal pro-
grams that provide essential inputs into the health resources of the

set

Region are: other activities of th. National inscstutes of Health

.

and National Institute of Neurological Diseases and Blindnass; othe
constituents of the Department of Health, Education, and We nlfave
particularly the Comprehensive Health Planning and. Services Progra

in the Office of the Surgeon General, the Bureau of Disease Drevypntion
and Environmental Control, the Bureau of Health Manpower, the bureau

>
particularly the National Heart Institute, National Cancer Tascituce,
2

DRAFT
4)

   
 

 

whee .
ot
oo Because tho advance of kmowlodie chvutins the mature of men ten
cave, Je Coo tration ean bent. he Viewed as con rot
nt rather than a plan whieh ib totally developed mad thes .

 

This process of regionalization, or cooperative arrangements, consiots
of at least the following clements: involvement, idontizication of
necads and opportunitics , assessment of resources, definition of
objectives, setting of priorities, implementation, and evaluation.
Whike these seven clements in the process will he deserived and dis-
cussed, separately, in practice they are interrelated, continuous and
often occur simultaneously.

Involvenent - The involvement and comaitment of individuals,

oe orgaaizaiivas and institutions which will engage in the activity of

a a Regional Medical Program, as woll as those which will be affected

_ by this activity, must undcriic a Regional Program. by involving in

‘the steps of study and decision all those in a region who are essential

to implementation and ultimate success, better solutions may ve ound,

woo" the opportunity for wider acceptance of decisions is improved,
eee inpLone:ieation of decisions is achieved more rapidly. Other at
to organize health resources on a regional. basis have experienced
difficulty or have been diverted from their objectives. because cuore
was not this voluntary involvement and commitment by the HECessacy

and
teu
u

Cipes

 

 

individuals, institutions and organizations. The Act is quite specizic
. - to assure this necessary involvement in Regional Medical Programs: at
‘ BCEANGS, for cxample, the minimun composition of Regional Acvisory Groups.

B.. 2 “he Act states these Regional Advisory Groups must include "“practlcing
“ 7) + physicians, medical center officials, hospital administrators, pepren |
sentatives from appropriate medical socictios, voluntary health’ agencies,
‘and representatives of other organizations, instit sutdons, and ‘dpencies

: concerned with activities of the kind to be carried on under the prog
_** and members of the public familiar with the need for the services provided
under the program." To ensure a maximum opportunity for success, the

1

’
composition of the Regional Advisory Group also should be refle ctive

 

of the total spectrum of health interests and resources of the entire
region, And it should be broadly representative of the geograpuic <
and all of the socioeconomic groups which will be served by the

Progvtat . 2

 

 

Aha, ' ,
:

of Health Services, the Social Security Administration, the Office of
Education, and the Social and Rehabilitation Service; and other
Government agencies, particularly the Office of Economic Oprortunicy,
tic Model Cities’ Program of the Department of Housing and Urban Develop=
ment, and the Veterans Administsnidon. New sources of posudbic: Sea pore
for activities related to a ku aul Medical Program should | be considered
during both the planning and operational phases.

‘

 

-—. 2
: ‘ne \ogdonal Advisory Group should provida overali advica and Sus vance
in the “planning and operational Program, zxon the initial steps onward,

a
: *s
‘ .

we
wr Ae
Uden ifieation of Necds and ‘Oppockunitios = A Rujional Kedieas vrograt
must ddentily the needs regarding heart disease, cancar, sltoce and
D os related discuses within tha entire Repion. Further, these needs must
bo stated in terms which offer opportuaitics for solution.
This process of identification of needs and oppoxvkuatcios fox

solution Yvequires a continuing analysis of the problems in deliveriun
the best medical care for the target diseases on a regional basis, and
it must go beyond a generalized statement to definitions which can be
translated into opurational activity. Particular opportcuaities may be -
‘defined by: ideas and approaches generated within the Kegion, cxtension
of activities already present within the Region, and approaches. and o
activities developed elsewhere which might be applied with the Region. |

Among various identified needs there also are often relationships
oa, which, when perceived, offer even greater opportunities for solutions.
“i The danger of "project vision," which is akin to tunncl vision, must

“be guarded against.

no In examining the problem of coronary care units throughout its hegioa,
“for example, a Regional Program may recognize that the more effective

“approach would be to consider the total problem of the treatment of

myocardial infarction patients within the Region. This broadened

_ approach on a regional basis enables the Regional Program to concscer
etre. the total array of resourees within its Region in relationship to 4
>" comprehensive progra:. for the care of the myocardial infarction pavicnt.
Thus, whac was a concern of individual hospitals about how to introduce
coronary care units has been transformed into a projece or group of
ae ‘related projects with much greater potential for ezfective and ed@icient
we utilization of the Region's resources to improve paticnt care. /

Peg "

See, Assossnent of Resources = As part of the process of regionalization,

- a Region must have continuously updated inventory of cxisting vesources
and capabilities in terms of function, size, unber and quality. Every
colt. effore should be made to identify and use existing inventorics, fiiiing

‘obo am the gaps as needed, rather than setting out on a long, expensive

 

 

It should be actively involved in the review and guidance and in the
‘i coordinated cvaluation of the ongoing planning and operating functions.
-- % It should be constituted to encourage cooperation among the titutions,

in
organizations, health personnel, and state and local health as
such as the health planning bodies being established un idev th
hensive Health Planning Program, Public Law 90-174. It shoul.
concerned with continuing review of the degree of relevance
planning and operational activitics to the objectives of che Regional
"i$ Medical Program and particularly with the cifectiveness of these.

activities in attaining the goal of improved patient care. The Advisory

« . ‘ ‘
. ; .

tac

5
 

 

configurations of resources to meet needs.

 

‘provide a base and imperative for action. In the creation of an initial

 

*
precess of creating an cntively new daventory.  Infovinatiou seucec, taciude
state and local heatth planadlag’ apencien, hospital and madieal usnoclations,
and voluntary agencies. The inventory provides a basis for dafoxrimed
judgments and priority setting on activities proposed Lor COvelo pintnd
under the Regional Progyam. Tt can also be used to identify losing
resourceg-“voids requiring new inveutiicnt--and to develop new |

Definition of Objectives ~ A Regional Program must be contiougusly
involved in the process of setting operational objectives to mece
identified needs and opportunitics. Objectives are interim steps
toward the Goal defined at the beginning of this Chapter, and
achicvement of these objectives should have an effect in the Region
felt fax beyond the focal points of the bnew eae activities. This
can be one of the greatest contributions £ Regional Medical Programs.
The completion of a new project to train nurses to care for cancer
patients undergoing new combinations of drug and radiation therapy,
for example, should benefit cancer patients and should provide © :
additional trained manpower for many hospitals in the Region, Tut

the project also should have challenged the Reg sion's nursing and

hospitals communities to improve the continuing and in-service
education opportunitics for nurses within the eg tion.

Settin. of Priorities - Because of limited wanpower, facilitics,
financing and other resources, a Region must assign some order of

 

“priority to its objectives and to the steps to achieve them, Bésices

the Limitations on resourecs, factors to consider includa: 1). balance
between what should be done first to mect the Region's weeds, in
absolute terms, and what can be done using existing resources anc! compen
tence; . 2) the potentials for rapid and/or substantial progress: toward 3
the Goal of Regional Medical Programs aud pronress toward regionalization ©
of health resources and services; and 3) Program balance in teras of

‘disease catcgories and in tern: of omphasis. on patient care, education
‘and research.

Implementation - The purpose of the preceeding steps has been to

 

-*, Group does not have direct administrative responsibility fox the Pro-

gram, but the clear intent of the Congress was that the Advisoxy Giuoud
would insure that the Regional } Medical Program is planned and! developed
with the continuing advice and assistance of a group which is. - broadly
‘representative of the health interests of the Region. The Advisory
Group is expected to prepara an annual statement giving its evaluation
of effectivencss of the regional cooperative arsangemants established
under the Regional Medical Program. '
 

 

 

ane ‘

bd ,

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operational program, no Region can attoupl to deterinine all of cine
program obfectives possible, design appropriate projects to mees all
the objectives and then assign priorities before seawing & grand to
implement an operational proyram walch encompasses all or even ose
of the projects. Implementation can occur with an initial opevacional
propyvam encompassing even a small number of well-designed projccts

which will move the Region toward the attainment of valid prograin

objectives, Because regionalization is a continuous process, a Rugion
is expected to continue to submit supplemental and additional operational
proposals as they are developed.

After the implementation of an operational program, there are! two
potential threats. co be avoided. One is that projects will Lose their
regional identitics by becoming institutional projects, and thercby

cancel the opportunity for the operational program to have Regidial
scope and effect. The other threat is that projects wili lose we
relationships one to another which maintain the interaction of patient
care, education and research. Preventing these breakdowns requires
- project and program administration of a high order; it aiso requires
sustained communications , involvement, and the application o£ evaluation
procedures. :

~ Evaluation - Each planning and operational \activity of a Repion, as
well as the overall Regional Program, should receive continuous,
"quantitative and qualitative evaluacion wherever possible. Evaluation
should be in terms of attainment of interim objectives, the process of
yee ioaualization, and bhe Goal of Regional Medical Programs.

Objective evaluation is simply a reasonable basis upon which 6
determine whecher an activity should be continucd o¢ altered, and,
ultimately, whether it achieved its purposes. Also, the cvaluation

“of one activity may suggest modifications of another activity which

would increase its effectiveness.

Evaluation implies carrying out whatever is fcasible within the state

“of the art and appropriate for the activity being evaluated. Thus,

 

evaluation can range in complexity from simply counting numbers ‘of
people at mectings to the most involved determination of behavioral

7 changes in paticnt management.

As a first step, however, evaluation entails a realistic attempt to

design activities so that, as they are implemented and finally concluded,

“4

some data will result which will be useful in: determining the degrec of
success attained by. the. activity:

 
 

judged by the extent to which it can be demonstrated that th

 

 

Criteria = Mvaluatte

   

1 Me lL Peopvains = The e¢giterioa
cer jay, the success OL a Ropdou in inp -Loimen ting the process os
reptouaiisation is the degree to which dt can be demonstrated

the Regional Program has implemented the
discussed in this Chapter:

  

 

chat
VON Ghsential clenents |

involvement, identification of neces and
CPSs assessment of resources, definition of objectives,

etiing of prioritics, implementation, and evaluation.

ULleamabely, the success of any Regional Medical Program must be

@ Regional
Program has assisted the providers of health services in developing a
system which makes available to everyone in the Region improved care

4
for heart disease, cancer, stroke, and related diseases.

 

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Attachment II

» & EXAMPLES OF AGTIVETIES

Regional Medical Programs, as cooperative endeavors for improving the
organization and quality of health services in these disease fields generate
a variety of desirable and interrelated outputs in addition to this prirsry
output. Indeed, some of these additional outputs are attainable only through
-. such cooperative ventures. Many of these additional outputs of program
“activities can be included in three general categorics; (a) Research and

 

“> development in health services; (b) Manpower training; and (c) Actual ‘delivery

"5 of gexrvices, including prevention, detection, and control of disease and its
 sequellae.

 

we Examples of actual program activities illustrate the diversit. of
= Outputs:

nue (a) Rescarch and Developme: in Health Services

| in developing their plans the x ‘onal medical programs have ‘indicated
- that if the goal of improved organization and delivery of health care is to
be met, some entirely new means must be developed, and then accepted by those
- rendering care. Many regions are using research talent in investigating new
“means for improving health care by testing them in the actual practice of
~omedicine.

1. Yemporary but life-threatening disorders of breathing, heart beat,
blood pressure, ctc. often accompany heart attack and stroke. The
region containing one of the Nation's most sophisticated ‘¢omputer
centers for monitoring such disorders has linkea four community
‘hospitals to the computer center at the Latter Day Saints Hospital |...
in Salt Lake City, and is studying ways by which automated monitor= ="
ing may be extended to all hospitals in the Region.: ,

 

2. The Intermountain Region and the University of Michigan Department
of Industrial Engineering together are describing the functions
-of specialized units for the care of patients with heart attacks.

Using systems and opera:ions research techniques, both theoretic

and actual model "coronary care units" will be constructed,
‘allowing for the most efficient and effective development of
these units throughout. the Nation. .

 

 

3.. To survive cancer, patients must be treated rapidly, vigorously,
and optimally. Physicians must not lose sight either of their
_ patients or of the latest advances in therapy. Four regions are
now experimenting with computerized registries of cancer .patients.
Physicians treating cancer patients will regularly receive reports
listing their patients and the type of cancer, the progress of the
-patient and a comparison of his progress with optimal progress, and
haa : the best types of therapy then available for that particular type
D of patient and cancers _ my oe aN Be

 

up

og See.
A
= 2-

D 8, 4. Vermont is experimenting with a systems approach to analyzing

the costs of medical care rendered within the Region, The use

ef modern analytical techniques to study, for example, population
distribution, disease incidence, treatment patterns, and economic
benefits of treatment will allow decisions to be made which best
fit the Region's particular economic constraints and thc general
constraint imposed by the necessity of moderating the increase

in the cost of health care. ~

: (bb) Monpower Training

Concern with service of any type leads imrediately to a considerstion

of manpower needs incluing the more efficient and effective utilization.
Régional Medical Programs has a direct charge to "improve generally tne
health manpower of the nation." This has led to consideration of kind,
number, and quality of health manpower. Educational activities improving
quality are important to Regional Medical Programs, but somewhat uncxpected
were tne needs demonstrated by Regions to seek new kinds and numbers of
health manpower. Shortages of personnel have resulted in two interesting

experiments;

Ll. Metropolitan New York City, having a shortage of trained manpower
put a surfeit of disadvantages and potentially employable persons
in its midst, is studying ways of developing health carcers,
training programs, and finally, placement programs for’ those
trained.

 

2, The Colorado-Wyoming Region, with a similar manpower shortage
but no untrained labor force upon which to draw, has developed
a different solution.

Colorado estimates that fewer than 15 percent of its residents
having high blood pressure are either identified or being
treated adequately, Since the required mass-screening, program
would be too great an effort for the Region's physicians, nurses
are being svecially trained as “nurse-practitioners," fully
competent to conduct a sophisticated screening program.

3. To increase the availability of trained manpower, Regions are
designing new attractions for "professional drop-outs": -
split shifts for nurses--broader carcer opportunities and
opportunities for career shifts by allicd health workers-- and
new types of on-the-job refresher courses are being offered.

4, Through a cooperative effort of Los Angeles County, ucLA, Usd,
Luc Charles E, Drew Medical Soniety (a component of the National
Medical Association), and the California Regional Medical Progran, |
a new community hospital and postgraduate medical education
program is being planned for the: vatts area of Los Angeles,
California, © ‘

t
":
&

@ (c) Delivery of Services

. While actual care of patients is not a primary activity of any
‘Region, many projects do result in the delivery of high quality services,
including prevention, detection, and control of diseases:

1.

 

 

3.

 

 

The legislative authority for "demonstrations of patient cars"
results in the best of care being given to a number of ,atients.
Yeior to the establishment of the Mississippi Regional Medical
Program, no hospital beds were available to the large number of
indigent negro or white patients with non-hemorrhagic stroke,

nor were neurologic specialists available to render expert care.
The establishment, through the Mississippi Regional Mcdical
Program, of a four-bed unit at the University of Mississippi

for the demonstration and teaching of comprehensive care for the
stroke patient, is resultic; in an example of excellent’ care
being available for the first time which will favorably influence
the quality of care provided to a large segment of the population
of the state.

The Tennessee-Mid South Region has responded to a specific need
of Meharry Medical College and a nearby Neighborhood Health Center,
sponsored by the Office of Economic Opportunity, for efficient and
rapid screening of patients for a variety of disorders., With the
expert assistance of Vanderbilt University, a multiphasic screening
laboratory is being planned. While the major question to be
nswered by this project is the best method to screen a Large
population for specified disorders, answering the question will
result in the much needed detection and subsequent treatment of
disease in the population to be served.

two Regions, Washington-Alaska and Tennessee Mid-South, - have
recognized that computation of the precise dose of radiation
required by a patient with a certain type of cancer is a
difficult and complex process. While the actual therapy can be
administered by technicians, the machine settings, the skin area
to be included by the radiation, and other factors can be calcu-
lated only by a few speciaily trained physicians, often’ not be be
found even where treatment facilities exist.

Two Regions, on opposite sides of the nation, have developed
computer programs for error-free dose calculations, and’ are
extending this service by telephone links between hospitals
and the computer, This has resulted in the optimal treatment

- of many more cancer patients. 5

é
-4-

A variety of projects have related to detection or controi of disease,
thus, in making available to their patients the latest advances in diagnosis
‘and treatment. Regions have recognized new techniques in identifyiag
populations at risk, and the population with carly, and therefore. more
treatable disease, °

Ll. Well Child Clinics, Head Start Programs, and practicing
physicians' offices are the resources for cardiologic consultation
ang case cinding in Georgia. Children with early and previously

‘ unsuspected heart disease ave identified and brought into programs
of prophylaxis, vocational and educational guidance, Thus, a
program initially identifying children with cardiac difficultics
expands to fulfill the total physical and social needs of the child.

Lee | 2. ‘the Advisory Committee to the Surgeon General on Urban Health
Bae Affairs stated: "The time has passed when action to provide
(comprehensive personal health) sexvices could be carried out
by compartmentalized institutions and isolated units. ‘Now it
is necessary for the various public and private componcnts to :
assure cffoctive delivery of all health services needed by each 0
individual." Multiphasic screening program initiated in Tennessee |
Mid-South Regional Medical Program and other Regions will identify
ok ; patients not only with heart disease, cancer, stroke, malnutrition,’
. : obesity, and diabetes, but also those with tendencies to diabetes,
@ , with hyperlipemic states, genital and cervical dysplasias, and
others. To s0 label paticnts will create a demand for a, "second-
generation" response, and compel an unpredictable expansion of
the program if patient needs are to be served and patients are
to be afforded "the latest advances in the diagnosis and treatment
of discases."

t

' 3. In Lowa, a program is developing for the detection, mdariagement, a.
and rehabilitation of pa.ients with a high risk of havinn a
stroke or who have already had one. This program, carricd out
by a team of physicians,’ nurses, and physical therapists, consists
primarily of consultation services and continuing education for
health workers. The team will regularly visit various parts of
the state. With broadened perception of the potential for earlier
detection, for more aggressive therapy, and for meaningful
rehabilitation, the incidence of stroke and resulting impairment
is expected to decline. The imagination and innovative energics | a.
of that Region are certain to multiply programs not yet implemented. ©