NATIONAL ASSOCIATION OF REGIONAL MEDICAL PROGRAMS, INC.



                                Sol
                   In




                         MEETING
                         HIGHLIGHTS
                         September 1975






















                                    INTRODUCTION



                                    The Primary Purpose of the National Association of Regional Medical Programs is to pro-
                                    vide information and educational opportunities in areas of pertinence to the members.
                                    The format of the assembly in San Diego was, therefore, designed to provide a spectrum
                                    of informational interchanges related to the theme of the development of a health system
                                    for the community.
                                    The program began with current perspectives regarding the National Health Planning and
                                    Resources Development Act of 1974 (P. L. 93-641) as viewed from state government, the
                                    federal administration, health care and institutional professionals. It proceeded to the
                                    presentations and discussions of successful programs in high priority areas such as access,
                                    manpower, regionalization, quality assurance, and implementation and regulation concern-
                                    ing current legislation, There were special programs on health cultural awareness, RMPs
                                    in transition, hypertension, and technical assistance centers. The conference culminated
                                    with provocative presentations and discussion of implementations for the future.
                                    Many individuals, both NARMP members and non-members, prepared materials and made
                                    important presentations to the assembly and we are most grateful for their very significant
                                    contributions. However, the real measure of success of any such program relates to the
                                    worth placed upon it by all participants. The members of the Program Committee endeav-
                                    ored to design the conference so that there would be much of value, both in information
                                    exchanged and in thought provoking stimuli. We sincerely hope that there was reasonable
                                    attainment of this objective.




                                                                                  J. S. REINSCHMIDT, M.D.
                                                                                  Chairman, NARMP Program Committee



                                                                     rv I                                       I RI             I








                                             The   atmosphere   of   high   resolve   to   overcome   problems   posed   by   Public    Law
                                             93-641,  present  at  the  opening  of   the   second   annual   meeting   of   the   National
                                             Association of Regional Medical Programs, persisted to the very end of the
                                             three-day  session  ---  with  one  change.  At  the  end,  resolve   was   coupled   with   a
                                             clear  picture  of  what  must  be  done  to  make  the  law  work,   the   result   of   con-
                                             centrated attention to an explanation of the law's anticipated impact on
                                             the health care delivery system.




                                                                          FIRST PLENARY SESSION

                                             The meeting, particularly in the two plenary sessions, provided  a  forum  for  expression  of
                                             opinions and concerns. To the first session came  representatives  of  government,  practicing
                                             physicians, hospital administrators, medical schools and other health interests.
                                             Few faulted the law's basic concept-access to quality health care for all at reasonable  cost.
                                             The concern was with the way the law proposed to achieve this, the Health Systems Agency             2
                                             organization mechanism, its operation, impact on various  segments  of  the  health  care  de-
                                             livery system, accountability and responsibility both as to  location  and  geographic  scope.



                                                                            STATE GOVERNMENT

                                             Robert D. Ray, Governor of  Iowa  and  Chairman  of  the  National  Conference  of  Governors,
                                             reminded the assembly that the mid-western governors  at  their  recent  conference  voted  to
                                             have P.L. 93-641 repealed in its entirety. The conference's main objection was to removing
                                             health planning from "public officials affected by, accountable and responsible to the people
                                             that elect them." Among suggestions  for  improving  the  law  were  provisions  for  complete
                                             care capability in each health service area, relaxation of population limits, permitting  gov-
                                             ernors of rural states with few HSAs to  name  a  reasonable  percentage  of  HSA  board  mem-
                                             bers in place of appointing a state coordinating body, and more emphasis on quality of
                                             HSA board membership and less on categorical representation.













                                                                              FEDERAL GOVERNMENT


                                                  Kenneth Endicott, M.D., Director of the Health Resources Administration, voicing need
                                                  for rapid communication during transition, announced formation of an RMP multi-regional
                                                  coordinators group to act as a special liaison committee between RMPs and the Depart-
                                                  ment of Health, Education and Welfare. Relating to Dr. Endicott through Dr. Margulies,
                                                  the committee is to function in an advisory capacity, identifying, collating and classifying
                                                  problems and issues.



                                                  Harold Margulies, M.D., former Director of the Division of Regional Medical Programs, now
                                                  Deputy Director of the Health Resources Administration, said more attention should be
                                                  paid to what will work than to the precise wording of the law. Cautioning against erosion
                                                  of expectations such as has occured in the past, he pleaded for their reduction so that the
                                                  law has a fair chance to work. He predicted HSA funding will be low and urged preserva-
                                                  tion of successful RMP projects through outside funding rather than hope forlornly for
                                                  continuation through HSAS.



                                                  Eugene Rubel, Acting Director, Bureau of Health Planning and Resources Development,
                                                  stated that the primary concern of HEW with regard to the new HSAs is the "caliber of
                                                  governing board members and the staff." He granted that technical changes in the law
                                                  were needed but added that changes could not be expected until after the law is imple-
                                                  mented and a number of HSAs established.

         3





                                                                       PHYSICIAN IN PRIVATE PRACTICE


                                                  Joseph F. Boyle, M.D., in private practice in Los Angeles, American Medical Association
                                                  trustee and speaker of the California Medical Association house of delegates, attributed
                                                  lack of success in past community health planning partially to provider non-participation,
                                                  and made a strong plea for providers to avoid repetition of this past mistake. "it is ra-
                                                  tional that those who have the experience and educational background participate as fully
                                                  as possible. It is also equally sensible that the people for whom this care is being planned
                                                  ... participate so that they receive what they perceive as an answer to their needs and
                                                  not an answer to the needs as perceived by someone who may never have been there
                                                  themselves."
                                                  Referring to the greater federal expectations from the new law to be achieved seemingly
                                                  with lower funding, Boyle warned of an apparent "impossible task" for the community
                                                  to undertake. He urged best efforts to make the law work because "if you fail in an im-
                                                  possible task, we may have to write some other kind of legislation to take care of it again
                                                  in the future."











                                      HOSPITAL ADMINISTRATION

           Stephen M. Morris, past president of  the  American  Hospital  Association  and  President  of
           Samaritan Health Service, Phoenix, Arizona,  reiterated  the  almost  universal  concern  over
           the discretionary power vested in HEW and the shift in health care  planning  from  the  local
           to the state and federal arena. He added that "federal leadership  and  direction  are  neces-
           sary to solve the health service problems that we face, and the regulation that follows  is
           inevitable. We in the profession have a duty to make sure that this regulation  is  a  good
           regulation and that it does what it is designed to do."

           He foresaw, as a rational development, the possibility of dividing  the  HSA  planning  and
           regulatory functions with regard to hospitals, with a  consortium  of  hospitals  doing  coop-
           erative planning.



                                           MEDICAL SCHOOLS

           Donald Brayton, M.D., medical director, Kern Medical Center, Bakersfield, California,
           spelled out an extensive list of  recommendations  from  the  Association  of  American  Medi-
           cal Colleges for inclusion in the federal guidelines. These  recommendations  dealt  with  the
           certificate of need process and federal use of funds, which he described as areas  of  primary
           concern to medical schools. The guidelines include  requirements  for  consideration  of  edu-
           cational goals of teaching institutions in the conduct of HSA  review,  criteria  development,
           timeliness of review, project renewal and continuation.


           "There could be no doubt but that P.L. 93-641 is possibly the most  intricate  piece  of  leg-                                           4
           islation ever developed. It's guidelines and recommendations must of  necessity  be  intri-
           cate. Our exchanges here will perhaps lead  to  more  workable  regulations  and  thereby  may
           ultimately enhance the law's effectiveness."







                                          SECOND PLENARY SESSION-
                 The second of the plenary sessions dealt mainly with in-house matters, with emphasis on
                 the future of successful RMP projects and future leadership in health matters.




                 Nathaniel Polster, NARMP Washington representative, expressed belief that if RMPs would
                 focus on programs of Congressional priority and demonstrate effectiveness they would not
                 only be likely to find funds for continuation of successful RMP projects but also would es-
                 tablish the kind of impressive record that results in leadership in re-writing P.L. 93-641
                 when the time comes.





                 Paul D. Ward, Executive Director of the California Regional Medical Program stated his be-
                 lief that we may be at the low end of the Congressional funding curve for health now and
                 must be ready to provide leadership when the upturn occurs. He urged RMPS, as the only
                 group which understands the needs of consumers and providers and which demonstrates a
                 comprehensive approach to health care, to continue the information flow to the legislative
                 and administrative branches of federal government, to see that health dollars get appropri-
                 ate priority, to use the multi-regional liaison committee to look for opportunities to provide
                 information for appropriations committee hearings, to develop public accountability re-
                 ports so that they are useful at the congressional and HEW levels and to work together to
                 develop a stance regarding extension legislation.









                                                                PLENARY AND LUNCHEON SPEAKERS


                                               P. L. 93-641 As Viewed by a Governor
                                                    The Honorable Robert D. Ray, Governor of Iowa and Chairman, National Conference
                                                    of Governors, State Capitol, Des Moines, Iowa 50319


                                               P.L. 93-641 - Expectations of the Federal Administration
                                                    Kenneth Endicott, M.D., Director, Health Resources Administration, 5600 Fishers
                                                    Lane, Rockville, Maryland 20852


                                               P. L. 93-641 - As Seen by a Practicing Physician
                                                    Joseph F. Boyle, M.D., California Medical Association, 731 Market Street, San Fran-
                                                    cisco, California 94103


                                               P.L. 93-641 - From the View of a Hospital Administrator
                                                    Stephen M. Morris, Past President, American Hospital Association; President Samari-
                                                    tan Health Service, 1410 North Third Street, Phoenix, Arizona 85002

                                               P. L. 93-641 - Impact on Medical Schools
                                                    Donald 0. Brayton, M.D., Medical Director, Kern Medical Center, 1830 Flower
                                                    Street, Bakersfield, California 93305



                                               Eugene J. Rubel, Acting Director, Bureau of Health Planning and Resources Development,
                                               Health Resources Administration, 5600 Fishers Lane, Rockville, Maryland 20852.
                                               Harold Margulies, M.D., Deputy Director, Health Resources Administration, 5600 Fishers      6
                                               Lane, Rockville, Maryland 20852.

                                               Nathaniel Poister, NARMP Washington Representative, 2128 Wyoming Avenue, N.W.,
                                               Washington, D.C. 20008,

                                               Paul D. Ward, Executive Director, California Regional Medical Program, 7700 Edgewater
                                               Drive, Oakland, California 94621.


















                                       The following workshop summaries present a distillation of 90 formal papers
                                       and panel discussions on health resource development activity nurtured by
                                       Regional Medical Programs. Detailed information may be obtained by writ-
                                       ing directly to the participants, whose addresses immediately follow these
                                       reports.

                                       Bold type introductions to each workshop summary are based on information
                                       developed by the national RMP Public Accountability Reporting Group.





        7


















                                                                                 ACKNOWLEDGMENT


                                                   Preparation of this San Diego meeting report was made possible with the generous  help  of
                                                   the following individuals: Roger L. Beck, Virginia Regional Medical Program;  June  Estes,
                                                   Mississippi Regional Medical Program; Patricia Estes, Tennessee Mid-South  Regional  Medi-
                                                   cal Program; J. R. Gallagher, Iowa Regional Medical Program;  Katherine  Herzog,  Arkansas
                                                   Regional Medical Program; Robert C. Hunt, South Dakota Regional Medical Program;
                                                   Linda R. Johnston, Texas Regional Medical Program; Steve F. McCourtie, Michigan Re-
                                                   gional Medical Program; Kay Page, North Carolina Regional Medical Program; Virginia
                                                   Rodgers, Memphis Regional Medical Program; J. P. Smith, Colorado-Wyoming Regional
                                                   Medical Program; Ellen Soo Hoo, Illinois Regional Medical Program; Jerold G. Sorensen,
                                                   Intermountain Regional Medical Program; Carol Sympson, Ohio Valley Regional Medical
                                                   Program; and Linda Wenze, Nassau-Suffolk Regional Medical Program.












                                 ACCESS TO  PRIMARY  CARE


                      The provision of primary care services for medically underserved populations is first among
                      ten priorities mandated for action under the provisions of Public Law 93-641. During the
                      year which ended June 30, 1975, Regional Medical Programs wholly or partially funded
                      some 550 new health service activities in the development of primary care services in rural
                      and medically underserved areas.



                                                                                Rural Programs
            Workshop participantsdiscussed problems concerned with ac-          Use of technical and financial support to establish 12 rural
              cess to primary care in urban and rural areas, with the effec-    community health centers was cited as  an  example  of  RMP
              tiveness of nurse clinicians and community health workers,        efforts to improve primary care access in rural areas. Fea-
              with the role of the university in primary care manpower pro-     tures of the program included: development of  fixed  sites
              duction and education, and with the  problems  facing  the        for services; commitment of local funds or services; provi-
              newly emerging Health Systems  Agencies  in  dealing  with ease   sion of varied types of health services; and establishment of
              of access and availability of health services.                    minimums for times and types of services offered. A  state-
                                                                                wide committee  on  primary  care  has  guided  implementation 8
              Some of the findings:                                             of the project, and will aid in evaluation.

              Urban Programs

              An example of an RMP function in an urban  area  was  pre-
              sented. One RMP effectively worked with Model Cities pro-         Manpower
              grams, using hospital-based resources, to establish and expand
              community ambulatory care centers. In this example, a dol-        An example of the evaluation of one type of  physician  ex-
              lar-for-dollar local match was required. These centers were       tender has produced preliminary evidence that use of  a  nurse
              rapidly accepted and continue their operations without R.MP       clinician in a rural solo practice can increase productivity by
              funds. The use of hospital-based resources provided several       20-30 percent. It would appear that increased use  of  such
              advantages:                                                       personnel might have a signif icant effect on the overall avail-
                                                                                ability of primary care.
                    Hospitals were already located in each of the
                    underserved areas. Use of these existing facili-            In another example, an RMP has a  task  force  studying  44
                    ties avoided the necessity for costly develop-              projects utilizing the Community Health  Worker  to:  describe
                    ment of new facilities or services;                         utilization patterns; standardize methods of training; develop
                                                                                credentialling procedures; and develop third party  pay  or
                    Physicians preferred delivering outpatient ser-             funding for community health worker services.
                    vices in the hospital setting, which offered ap-
                    propriate facilities and services, including estab-
                    lished administrative systems.
                                                                                Role of the
              In another example, an  RMP  incorporated  a  hypertension
              screening program sponsored by an inner city neighborhood         Panelists agreed that universities had not taken the lead in
              health center as a means of stressing The importance of  a        improving access to primary care, citing  their  preoccupation
              specific disease process in an ambulant, black population.        with other activities, and the lack of appropriate  encourage-
              The intent was to develop or modify patterns of utilization       ment from federal funding sources. However, medical
              of available resources. Through a  successful  program  of        schools are now perceiving primary health care as a  desirable
              detection, treatment, and improved compliance, the hyper-         avenue for teaching and research. A number of  state  legisla-
              tension orientation  augmented  the  comprehensive  health        tures, who provide a large portion of medical school  budgets,
              care services offered by the center. Indigenous  personnel        have been urging production of  more  primary  care  providers
              were trained and used as outreach workers in the  project.        and decentralization of the education process.









                Problems for Health Systems Agencies                                   Conclusions

                There is a necessity for HSAs to build on the RMP experience           Participants in the @,vorkshop expressed the ollowing strong
                with respect to access to primary care. The following sugges-            concerns:
                tions were offered,
                                                                                             1.  It is vital that the accomplishments of
                      1.  Involve public officials in the planning pro-                          RMPs in ir-nidlementing programs to im-
                          cess to facilitate implementation and con-                             prove access and availability of health
                          tinuation of health programs.                                          services be recognized as a basis for  con-
                                                                                                 tinued expansion.
                      2.  Provide educational programs   for people in-
                          volved in the planning process.                                    2.  There is no central  agency  in  Washington
                                                                                                 responsible for improving access to pri-
                      3.  Coordinate the effective use of local resources.                       mary care, a  high  priority  component  of
                                                                                                 P.L. 93-641. This situation contributes
                                                                                                 to the slow realization of the solution  of
                                                                                                 this complex problem in health care
                                                                                                 del ivery.












        9






                                WORKSHOP PARTICIPANTS

                                ACCESS TO PRIMARY CARE


                 Moderators:
                                Robert W. Brown, M.D., Director, Kansas Regional Medical Program, 4125 Rainbow
                                Boulevard, Kansas City, Kansas 66103
                                Marlene Checel, M.P.H., Director, Access to Primary Care Program, California Regional
                                Medical Program, 7700 Edgewater Drive, Oakland, California 94621
                                John A. Mitchell, M.D., F.A.C.S., Associate Professor, Community and Family Medi-
                                cine, University of Arizona, 1501 North Camel Avenue, Tucson, Arizona 85724

                    Panelists:
                                Improving Access to Primary Care Through Hospital-Based Ambulatory Services
                                in New Jersey
                                Alvin A. Florin, M.P.H., Coordinator, New Jersey Regional Medical Program, 7 Glenwood
                                Avenue, East Orange, New Jersey 07017


                                Health Center Development in Arizona
                                Phyllis Reifurth, Health Systems Specialist, Arizona Regional Medical Program, 5725 East
                                5th Street, Tucson, Arizona 8571 1
                                Problems for the Health Systems Agencies in Access and Availability of Primary
                                Care
                                John A. Mitchell, M.D.                                                                          10
                                Role of University in Improving Access to Primary Health Care
                                John A. Packard, M.D., Associate Dean, University of Alabama, College of Community
                                Health Services, P. 0. Box 6291, University,Alabama 35468
                                Categorical Entry to Primary Care - Projec t High Blood: Screening and its
                                Aftermath
                                Samuel U. Rodgers, M.D., M.P.H., Project Director, Wayne Miner Neighborhood Health
                                Center, 825 Euclid, Kansas City, Missouri 64124

                                The Community Health Worker
                                Gloria Ellis, Community Health Worker Component, Access to Primary Care, California
                                Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621

                                A Physician-Extender Study
                                Geraldine C. Holmes, Ph.D., Planning and Evaluation, Kansas Regional Medical Program,
                                4125 Rainbow Boulevard, Kansas City, Kansas 66103
                                Development of Primary Health Care Services in Los Angeles County
                                Loren G. McKinney, M.D., Assistant to Medical Director, Department of Health Services,
                                313 North Figueroa Street, Room 805, Los Angeles, California 90012

                                The Challenge
                                Teresita Moreno, Program Officer, New Mexico Health Cultural Awareness Program,
                                2701 Frontier Place, N.E., Albuquerque, New Mexico 87131



















             MANPOVVER




                          The number of health professionals trained in new roles by RMP's for an 18-month period
                          extending through June, 1975 has been estimated at 32,456.  Categories include nurse
                          practitioners, physicians' assistants, emergency medical technicians, and others.  For the
                          corresponding period, it is estimated that 5,120,000 people were served by these RMP-
                          trained new health manpower providers.


                 The   Health   Manpower   Workshop   intended   to   step   outside      When these tools are designed in cooperation with their
                 the day-by-day living and working experiences of health                  users, local planners and decision makers; when these tools
                 manpower   planners,   educators,   and   employees.    One    half      are powered by accurate, timely, appropriate data; and
                 of  the  program  was  devoted  to  identification  of  key  issues      when these models are respected as abbreviated representa-
                 and changing  priorities  with  regard  to  h@alth  care  delivery/      tion of reality; then they may be effective methods for
                 education   systems.   The   second   segment    examined    recent      determining future manpower supply and demand.
                 work in the application of social science technology to
                 health manpower planning.                                                Several "micro" health manpower models were described.
                                                                                          The thrust of these econometric efforts is the development
                 One effective method for assuring balanced health manpower               of specific information for local level use in reaching health
                 planning  from  small  communities   to   statewide   or   regional      manpower planning decisions.
                 areas  -  is  through  the  comprehension  and   amplification   of
                 existing  linkage  systems.  An  individual  linkage  is  the  con-      The sessions also received a detailed technical presentation
                 nection  or  relationship  between   two   functions   or   between      on a new "micro" health manpower model. Such instru-
                 two people; a linkage system is  the  sum  of  all  the  individual      ments are designed for use on regional, interregional or
                 linkages.                                                                even national scales and may provide unique and useful
                                                                                          insights into the over-all manpower arena.
                 Many  different   agencies   and   organizations   conduct   health
                 manpower  planning  activities.   Seldom   does   any   one   group      The conference shifted from reviewing planning and model-
                 direct  its  planning  at  the  broad  range  of  health   manpower      ling, to considering finds and conclusions from a number
                 as it is related to  the  total  health  care  delivery  system,  A      of specific strategies. These projects are aimed at health
                 statewide  linkage  system  concept  is  most  useful   when   com-      manpower solutions in the nurse practitioners, physician
                 bined with a step-by-step planning process. Suggested                    assistant, and physician extender realms.
                 process steps include:  (1 ) assemble staff, (2) develop a
                 work  plan,  (3)  determine  current  process,  (4)  develop  link-      The group studied some of the problems of developing, plac-
                 age  mechanism,  (5)  develop  planning   process,   (6)   identify      ing and evaluating innovative efforts for health manpower
                 future  conditions,  (7)  determine   manpower   supply   and   de-      and related health programming strategies.
                 mand, (8) alternate  strategies  developed,  (9)  draft,  test  and
                 publish  a  health  manpower  plan,  and  (10)   develop   a   data      It was noted that most innovations come as a result of the
                 collection system.                                                       efforts of a single charismatic person. When he leaves, the
                                                                                          innovations vanish.
                 The decisions and   priorities  generated  by   the   health   man-
                 power  planning  process   are   augmented   by   health   manpower      Innovations in health manpower education were studied.
                 econometric models. It is important that these models                    It was stressed that these approaches (AH EC, HS/EA, VA
                 be  considered  as  tools  for  employment  in  the   health   man-      and others) are but one resource in the development of
                 power planning process.                                                  a community health education system. Community health





                 education efforts continue to be a prime consideration,             The health manpower workshop ranged through process
                 since, historically, health education programs have done            for (1) developing small community data, to (2) statewide
                 much in shaping the delivery of health care.                        planning and to (3) the federal dilemma in applying
                                                                                     national programs to regional requirements.
                 The importance of decision makers (gate keepers) in social
                 action programs was stressed. Highlight of the workshop             The challenge may be summed up in the idea that health
                 was a description of 40 years of technical work which re-           planners, especially health manpower planners, should be
                 sulted in the use of such models as the BHSDS, EMCRO,               aware of social, political and economic factors; but they
                 UHDD, and PSRO.                                                     should be keenly aware of the differences between what
                                                                                     they, as planners, think is needed and what is really needed.



                                                     WORKSHOP PARTICIPANTS

                                                     MANPOWER
                                Moderators:          Donald G. Brekke, Director, South Dakota Regional Medical Program, 216 East Clark
                                                     Street, Vermillion, South Dakota 57069
                                                     C. Kenneth Proefrock, Executive Director, Mahoning Shenango Area Health Education
                                                     Network, 5211 Mahoning Avenue, Youngstown, Ohio 44515
                                                     Charles W. White, Ph.D., Program Director, California Regional Medical Program,
                                                     7700 Edgewater Drive, Oakland, California 94621



                                   Panelists:        Summary Analysis of Health Manpower Models
                                                     Timothy C. Doyle, Ph.D., Program Director, Vector Research, Inc., P. 0. Box 1506,
                                                     Ann Arbor, Michigan 48106                                                                    12
                                                     Manpower Planning Models and Quality Assurance
                                                     Paul Sanazaro, M.D., Director, Private Initiative & Professional Standards Review Or-
                                                     ganization, 703 Market Street, Suite 535, San Francisco, California 94103
                                                     Overview of the AHEC, VA, HS/EA Consortia Models
                                                     Lawrence H. Miike, M.D., J.D., Research Director, UC San Francisco Health Policy
                                                     Program, Washington Study Group, 1828 L. Street, N.W., Suite 700, Washington, D.C.
                                                     20036
                                                     Some Economic Aspects of Health Manpower Planning
                                                     Donald E. Yett, Ph.D., Director, Human Resources Center, University of Southern
                                                     California, Los Angeles, California 90007
                                                     Congressional Viewpoint on Health Manpower
                                                     Carl A. Taylor, Health Manpower Manager, Office of Technology Assessment, Congress
                                                     of the United States, Washington, D.C. 2ooo6
                                                     Problems of National and Areawide Plarining for Appropriate Distribution of
                                                     Health Personnel
                                                     William Shonick, Ph.D., Associate Professor of Public Health, University of California,
                                                     Los Angeles, California 90024

                                                     Health Manpower Linkage Systems
                                                     B. Jerald McClendon, Project Coordinator, Health Manpower Planning and Linkage
                                                     System, State Department of Health, Pierre, South Dakota 57501
                                                     Innovations in Health Manpower Training and Utilization
                                                     Charles E. Lewis, M.D., Chief of Division of Internal Medicine and Health Research,
                                                     University of California, Los Angeles, California 90024

















                              WORKSHOP III - REGIONALIZATION ACTIVITIES








                          Regionalization of services has been a major RMP goal from the beginning.  During calendar
                          years 1970 through 1974 it has been estimated that 10,962,000 patients received direct health
                          services in demonstration projects having strong regionalization of secondary and tertiary care
                          components.  In 1974 alone, 2,276,000 persons received direct health services for heart dis-
                          ease, cancer, stroke, kidney, hypertension, pulmonary disease, arthritis and other disorders.
                          Regionalization system development --- statewide kidney transplant and dialysis networks,
                          regional referral and transportation systems for neonatal intensive care, arthritis centers and
                          support networks and other services --- received more than $25 million, 22 percent of all RMP
                          1974-75 awards.



           13   Perinatal - Neonatal                                                     Hypertension
                Although the value of perinatal centers has been extensively             The RMP commitment to community-level management
                documented---one center recorded a drop in high risk infant              of high blood pressure often linked with the early involve-
                mortality, from 200 per 1,000 to 150 per 1,000 --- panelists             ment of the American Heart Association, has spawned a
                agreed with the sentiment that "if medical care is offered               variety of approaches. In one instance, a cardiovascular
                on a per pound basis, then newborns certainly need some-                 disease network, established after task forces recommended
                one to fight for them."                                                  secondary and tertiary care programs, is now serving more
                                                                                         than half the health districts of one state and the remainder
                Outreach education is for many RMP projects the first step               are expected to become involved in the coming year.
                toward regionalization of neonatal intensive care. "Mini-
                fellowships", in which physicians spend up to 10 days at a               Other projects dealing with screening and treatment within
                tertiary center as full members of the NIC unit staff and                the existing health care system coupled with effective follow-
                performing hitherto unfamiliar techniques, have encouraged               up were supported in high impact urban settings, emphasizing
                participants in one project to train their own nurses in NICU            peer group pressure "on the job." In one, control rate of 82
                techniques back home, starting the nucleus of a perinatal                percent was achieved largely because of easily accessible care.
                team for comprehensive infant care in the community. This                Detection and readily available treatment are an effective
                "ripple" method of continuing education has helped to                    team.
                overcome many problems encountered in neontal/perinatal
                health care delivery; for example, infrequent deliveries in              Another approach used a statewide council to provide coor-
                large, but sparsely populated geographic areas, the failure              dination and technical assistance, establish priority activities,
                to transport patients appropriately among facilities, and the            target efforts and assure evaluation, As a result, nine service
                tendency of a physician to overextend himself by perform-                areas around medical centers were established.
                ing delicate techniques in which he is not proficient.
                                                                                         Efforts at hypertension control in isolated, small rural com-
                NICU ideal conditions will have been reached when high                   munities, hampered by physician shortages and inadequate
                risk mothers are routinely detected beforehand, and their                transportation, has often led to the organization of commun-
                pregnancies completed in effectively managed centers.                    ity groups whose purpose is to deal with high blood pressure
                                                                                         services and to seek widespread public utilization. A recently
                However, such centers require expensive equipment and                    instituted mobile unit seems in one project, to be more suc-
                personnel not likely to be replaced as the RMP structure                 cessful in attracting large numbers of the public than a
                disappears as the result of Public Law 93-641.                           stationary clinic.








                                                                                                  in-service education for hospital and nursing
                                                                                       education,
                                                                                       home  staffs  and  a  comprehensive  clinic  program  staffed   by
                                                                                       physician assistants in three rural communities.

                                                                                       Still a different type  of  regionalization  project  by  an  RMP,
                                                                                       concerned itself with adverse  drug  reactions  suffered  by  pat-
                                                                                       ients in 10  participating  hospitals.  Patients  were  monitored,
                                                                                       reactions  recorded  and  controlled.  The   additional   pharmacy
                                                                                       and drug information and poison control data have been
                                                                                       shared, and  the  project  provides  continuous,  easy  access  to
                                                                                       the  latest  pertinent  information  through  a  network   serving
                                                                                       450,000 patients per year.

                                                                                       Kidney Disease Control
                                                                                       Necessary  components  for  a  successful  kidney   disease   con-
                                                                                       trol program are   a transplant center, facilities for tissue
             Emergency Medical Services                                                typing,  organ  preservation   and   organ   procurement   center,
                                                                                       limited care services, home and  satellite  dialysis,  and  ancil-
             The amalgamation of diverse political jurisdictions to build              lary laboratory facilities. Most of  the  projects  described  for
             a truly regional EMS system can involve major obstacles to                panelists  were  begun  five  years  ago  and  included  statewide
             success. Included among them are a lack of contact and                    kidney   disease   information   systems,   nephrology    manpower
             communication with top executives of the various jurisdic-                studies, formation of a society  of  transplant  surgeons,  train-
             tions, Federal Communications Commission rules changes                    ing of surgeons in  renal  transplantation  and  professional  and
             and radiobroadcast problems. The planning and implemen-                   public education designed to lead to organ procurement.
             tation of improved emergency health care must, however                    Traditional  physician  cooperation  to  improve  care   of   end-
             difficult, include at the earliest stages a realistic plan for
             evaluation of the developing system. Rural EMS systems,                   stage renal  disease  patients  has  recently  been  augmented  by
             panelists were told, suffer from a number of special prob-                joint  efforts  in  organ  sharing,  cooperation  in   immunology,
             lems, among them, the absence of even one conforming                      organization  of   common   transplant   recipient   pools,   more 14
             ambulance, lack of appreciation for the elements desired                  formal  referral  and  organ  harvesting  networks,  and   passage
             and the importance of quality EMS, and a geographic terri-                of pertinent legislation.
             tory and population mix that are not in compliance with
             funding agency requirements.                                              Professional  education  efforts  have  been  highly   successful,
                                                                                       with high  attendance  at  training  workshops,  and  dramatically
             Other Regionalization Activities                                          improved  viability  of  harvested  organs  and  organ   retrieval
                                                                                       rates.
             Inadequacies in rural health care delivery were reduced in one
             region by a project designed to have a large well established             One  project  concerned  with  public  education  funded   through
             group practice clinic coordinate services throughout more                 the Kidney  Foundation  found  that  three  out  of  four  persons
             than 100 hospitals and clinics. Outreach activities included              surveyed expressed  positive  feelings  about  medical  transplan-
             physician consultation, computer assisted electrocardiography.            tation, and better than half felt positive about donating
                                                                              I
             reference laboratory, blood banking, equipment repair and                 specific parts of their own bodies.
             maintenance, psychiatry, psychology and psychiatric social
             services, electroencephalographic interpretation, neonatal                Many states have recently  passed  legislation  authorizing  organ
             emergency care, pulmonary function testing and remote con-                donor pledges on driver licenses, millions of  dollars  for  hemo-
             tinuous cardiac monitoring.                                               dialysis, new definitions of death  and  the  easing  of  restric-
                                                                                       tions on home dialysis patients.
             Solutions in one large state with complex geographical and cul@
             tural barriers were found by opening many new clinics and
             generating local support. Supplementary services were devel-              Arthritis Control
             oped by recruiting and training interested community mem-
             bers to coordinate and monitor local planning efforts and                 A shortage of physicians  specializing  in  rheumatology,  a  sev-
             health programs.                                                          vere maldistribution of those  who  practice,  and  a  clear  need
                                                                                       for continuing  education  of  doctors,  nurses,  physical  thera-
             Panelists heard of a 10-year old program that began in a large            pists,  social  workers,  and  allied  health  care  team  members
             state as a home health agency. Since RMP involvement, it                  hamper  this  emerging  medical  specialty.  Panelists  were  told
             has added early and periodic screening; diagnosis and treat-              that fewer than 500 physicians are  board  certified  in  the  na-
             ment, lead poisoning and senior citizen screening, family                 tion; most are  in  California,  and  those  are  concentrated  in
             planning, alcoholic rehabilitation and detoxification, dental             Los Angeles - San Francisco. This occurs in spite of the





               fact that patients appear to be evenly distributed throughout             problems such as in-service training needs, shortage and
                                                                                         turnover of personnel, communication and practical "do it
               the Country.                                                              yourself" answers can lead to many benefits and, eventually,
               Against this background, innovative solutions are sought. In              to self-sufficiency through cost savings. Sharing of lessons
               one project, a rural care model @-vas developed. Local physi-             learned in fiscal management and administration, and in
               cians identified as community coordinators were combined                  developing acceptable peer review systems are other out-
               with other health personnel to compose a local arthritis care             comes that lead to additional benefits.
               team. Consultative clinics and patient family education were
               held in local communities with visiting consultants examining,
               evaluating and prescribing comprehensive treatment that was               Cancer Control
               to be carried out by the referring physicians.
                                                                                         Regionalization of RMP-funded cancer control projects has re-
               Arthritis centers may focus on development of sub-regional                sulted in a higher quality of care for cancer patients, more ef-
               clinics, special problems of children with arthritis, professional        ficient utilization of medical personnel and the ability to cen-
               and lay education, assistance and regular physician visits to             tralize certain key services previously handled by disparate or-
               widely dispersed communities, evaluation, follow-up and                   ganizations.
               monitoring of patient progress, and linking all state physicians
               into a medical information service system by telephone.                   Panelists were told that successful cancer regionalization ac-
               Another goal is to establish rheumatology as a high-need                  tivities have several characteristics in common. Usually the
               specialty among physicians, nurses and other health care     pro-         project relates to health problems that no single agency can
               viders, with special emphasis on those physicians in training             handle alone. Usually the project affects a large geographic
               for family practice. Not forgotten are the all important pol-             area and involves some highly specialized activity or some
               icy-making medical institution administrators.                            technology that is new, scarce and expensive. Participating
                                                                                         institutions in the regionalization activity include those or-
               Cost Sharing                                                              ganizations that were recognized centers of excellence before
                                                                                         the project was initiated. Results can build closely-knit
               Objectives of shared services include the provision of other-             networks of major therapy resources, statewide tumor reg-
               wise unavailable services, prevention of loss of autonomy to              istries, radiation therapy and visiting consultant programs,
               otherwise stronger forces,- i.e., government or competing or-             annual statewide cancer workshops, facility planning and
               ganizations,  through  cost  reduction,  bet!'-,r patient care, re-       development for new centers, clinical traineeships, shared
         15    duced inventory, and attempting to satisfy competing de-                  allied health personnel projects and vastly improved patient
               mands and consumer criticisms. Cooperation on common                      ca re.










                             VVORKSHOP PARTICIPANTS


                             REGIONALIZATION ACTIVITIES


                             Perinatal-Neonatal



                    Moderator:


                             Sheldon Korones, M.D., Newborn Center, John Gaston Hospital, 860 Madison Avenue,
                             Memphis, Tennessee 38103

                     Panelists:


                             A Multi-State Rural System Development Effort in Neonatal Care
                             Sidney C. Pratt, M.D., Project Director, P. 0. Box 2829, Great Falls, Montana 59401

                             Regionalization of Neonatal and Perinatal Activities
                             Sheldon Korones, M.D.

                             The Regionalization of Perinatal Care in VVisconsin
                             Craig Anderson, M.D., 5721 Odana Road, Madison, Wisconsin 53719

                             Florida's Perinatal Program
                             Richard Boothby, M.D., Project Director, Hope Haven Children's Hospital, 5720
                             Atlantic Boulevard, Jacksonville, Florida 32207
                             Regionalization of Perinatal Care in the State of Kansas                           16
                             Howard Fox, M.D., Department of Pediatrics, University of Kansas Medical Center,
                             Rainbow Boulevard at 39th, Kansas City, Kansas 66103


                             Hypertension

                    Moderator:

                             Elliot Rapaport, M.D., President, American Heart Association, 1370 Mission Street,
                             San Francisco, California 94103



                    Panelists:

                             Regionalization of Hypertension Services
                             Morris M. Bradley, 938 Peachtree Street, N.E., Atlanta, Georgia 30309

                             The Future of Community Hypertension Control Funding Under Recent
                             Federal Legislation
                             Howard J. Bochnek, M. E., Coordinator of Hypertension Control Program, Metro-
                             politan New York Regional Medical Program, 2 East 103rd Street, New York, New York
                             10029

                             Regionalizing High Blood Pressure Control in California
                             Adelbert L. Campbell, Director, Program Coordination and Development, California
                             Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621







                 Development of a Statewide Hypertension Registry Program
                 Robert S. John, Assistant Director of Program Development, Illinois Regional Medical
                 Program, 122 South Michigan, Room 939, Chicago, Illinois 60603

                 Planning for a Hypertension Control Program in a Rural Area
                 John L. lsbister, Chief, Bureau of Community Health, Michigan Department of Public
                 Health, 3500 North Logan, Lansing, Michigan 48914


                 Emergency Medical Services

        Moderator:

                 James 0. Page, Project Director, Lakes Area Regional Medical Program, 2929 Main
                 Street, Buffalo, New York 14214



         Panelists:

                 Regionalization of Emergency Medical Services Activities
                 Vaughan E. Choate, 2007 1 Street, N.W., Washington, D.C. 20006
                 Regional EMS Program: An Example of Cooperative Planning and Funding
                 Alan Dimick, M.D., Department of Surgery, University of Alabama, University Station,
                 Birmingham, Alabama 35294

                 Emergency Medical Service in Northeast and North Central Missouri
                 Jacqueline C. Hall, R.N., Kirksville College of Osteopathic Medicine, Kirksville,
                 Missouri 63501

    17
                 Review of Developing Rural EMS Systems
                 Richard Walsh, M.D.; Joan Baker, R.N., 2701 Frontier Place, N.E., Albuquerque,
                 New Mexico 87131



                 Other Regionalization Activities


        Moderator:
                 Gordon R. Engebretson, Ph.D., Director, Florida Regional Medical Program, 1 Davis
                 Boulevard, Suite 307, Tampa, Florida 33606


         Panelists:
                 North Central Outreach Program
                 David L. Draves, Director, Regional Medical Services, Marshfield Clinic, Marshfield,
                 Wisconsin 54449

                 Regional Health Resources Development in New Mexico
                 Frank A. Otero, Project Director, Community Health Resource Development Project,
                 New Mexico Regional Medical Program, 2701 Frontier Place, N.E., Albuquerque, New
                 Mexico 87131

                 Regionalization of Health Services in Central Maine
                 John LaCasse, Deputy Coordinator, Maine Regional Medical Program, 295 Water
                 Street, Augusta, Maine 04330






                             Regional Drug Information Network
                             Carol McCarthy, Associate Director, Nassau-Suffolk Regional Medical Program, 1919
                             Middle Country Road, Centereach, Nevv York 1 1 720

                             Kidney Disease Control


                    Moderator:
                             Frederiel< C. Whittier, M.D., Chief, Nephrology Section, Veterans Administration
                             Hospital, 4801 Linwood Boulevard, Kansas City, Missouri 64128


                    Panelists:
                             Impact of RMP on End Stage Renal Disease in Arkansas
                             Tom E. Brewer, M.D., Assistant Professor, University of Arkansas for Medical Sciences,
                             4301 West Markham Street, Little Rock, Arkansas 72201

                             Experience with Criteria Setting in Two Dialysis Units
                             Arlene Sukolsky, Kidney Project Director, California Regional Medical Program, 7700
                             Edgewater Drive, Oakland, California 94621

                             A Survey of Public Opinion on Transplants
                             Jackie K. Reinhardt, Coordinator, Transplantation Council of Southern California,
                             1281 Westwood Boulevard, Suite 207, Los Angeles, California 90024

                             Chronic Kidney Disease Patient Care Systems
                             H. Earl Ginn, M.D., Chief, Nephrology Division, B2218 Medical Center, Vanderbilt
                             University, Nashville, Tennessee 32232

                             The Renal Program for Texas
                             Robert Humble, Deputy Director, Community Programs, Texas Regional Medical Pro-    18
                             gram, 4200 North Lamar Boulevard, Room 200, Austin, Texas 78756



                             Arthritis Control


                Moderator:

                             David D. Shobe, The Arthritis Foundation, 1629 "K" Street, N.W., Washington, D.C.
                             20006

                  Panelists:


                             Intermountain RMP Discrete Arthritis Activity
                             Steven J. Anderson, M.D., 325 Seventh Avenue, Salt Lake City, Utah 84103

                             Arthritis Activities of the Tennessee-Mid South RMP
                             Richard 0. Cannon II, M.D., Director, Tennessee-Mid South Regional Medical
                             Program, 1 10-21st Avenue South, Suite 1 100, Nashville, Tennessee 37203

                             California RMP Pilot Arthritis Program: Initial Steps Toward the Regionaliza-
                             tion of Care for Patients with the Rheumatic Diseases
                             Charlene Brax, M.P.H., Arthritis Project Director, California Regional Medical Program,
                             7700 Edgewater Drive, Oakland, California 94621

                             A Model Center-To-Clinic Project
                             Gene V. Ball, M.D., Professor of Medicine, Division of Immunology and Rheumatology,
                             University of Alabama in Birmingham, University Station, Birmingham, Alabama 35294







                        Cost-Sharing


               Moderator:

                        Albert M. Donnell, Coordinator, Oklahoma Regional Medical Program, P. 0. Box 26901,
                        Oklahoma City, Oklahoma 73190

                 Panelists:

                        Oklahoma Regional Health Development Area Program (RHDAP)
                        Albert M. Donnell

                        Green Hills Area Cooperative Health Care Project
                        Herbert Henry, Noll Memorial Hospital, Box 428, Bethany, Missouri 64424

                        Regionalizing Management
                        John Richey, Assistant Director, Grants Management, California Regional Medical
                        Program, 7700 Edgewater Drive, Oakland, California 94621

                        Regional Medical Audit Review System
                        Jack Rorex, Director, Health Planning, White River Planning and Development District,
                        P. 0. Box 2396, Batesville, Arizona 72501

                        Cancer Control


               Moderator:

                        Alfred M. Popma, M.D., 1903 S. Roosevelt, Boise, Idaho 83704

     19          Panelists:
                        The Illinois Cancer Council: An Experiment in Regionalization
                        Lorraine C. Hannah, Program Administrator, Illinois Cancer Council, 122 S. Michigan,
                        Room 939, Chicago, Illinois 60603
                        Automated Treatment Planning for Radiation Therapy in Arkansas
                        Alex P. Turner, Ph.D., Assistant Professor, University of Arkansas for Medical Sciences,
                        4301 West Markham, Little Rock, Arkansas 72201

                        Regionalization of Cancer Services
                        Francis Morrison, M.D., University of Mississippi Medical Center, Jackson, Mississippi
                        39216

                        The Regionalization of Cancer Services in Georgia
                        Don J. Trantow, 938 Peachtree Street, N.E., Atlanta, Georgia 30309


















                                 QUALITY ASSURANCE PROGRAMS













                         Quality Assurance of health care has been a priority area for RMP resources since 1970.
                         From that time through June, 1975 it is estimated that 143,820 health professionals have
                         been trained in techniques to systematize standards for and determine deficiencies in medi-
                         cal care, develop corrective action and implement activities which result in demonstrably
                         improved quality of care.



             The Quality Assurance Workshop provided a forum in                          The process of establishing criteria has been improved by in-        20
             which twenty-eight speakers presented information on          a             cluding patients as participants on hospital medical audit
             variety of RMP-funded efforts to improve patient care                       committees. The multidisciplinary approach, which includes
             through  quality  assurance  projects.  Papers  dealt  with   pro-          physicians, nurses, medical records administrators, hospital
             grams in  hospitals,  nursing  homes,  and  home  health  care  in          administrators and trustees, pharmacists and dentists, has
             both  urban  and  rural  settings,  the  development  of   innova-          proved highly effective in meeting JCAH and PSRO require-
             tive  collaborative  arrangements  between  disciplines  to   pro-          ments. Peer review of emergency room medical records has
             vide quality care, attempts  to  establish  and  evaluate  quality          proven as effective as physician interview and examination
             care  standards,  management  criteria   and   performance   feed-          of patients after discharge.
             back for specific diseases such as hypertension, coronary and
             pulmonary  disease,  and  for  laboratories.  Discussion  of  Pro-
             fessional  Standards  Review   Organization   (PSRO)   and   Joint          Non-Hospital Quality Assurance Programs
             Commission  on  Accreditation   of   Hospitals   (JCAH)   involve-
             ment concentrated on current functions, relationships                       Although efforts to evaluate patient care in ambulatory
             between professional organizations and RMPS, and the                        settings are not yet mandatory, nor as developed as hospital
             future of health care quality assurance from the federal      per-          programs, studies are being conducted to test various current
             spective.                                                                   methods of evaluating ambulatory care.

             Hospital Quality Assurance Programs                                         An attempt is being made to validate the "tracer" method
                                                                                         utilizing discrete, identifiable health problems in relation to
             Quality assurance efforts should maintain and improve medi-                 one another.
             cal care of patients, and  outputs  should  be  professional  edu-
             cation,  development  of  new  programs  of  patient  care  and             The relationship between process and outcome approaches
             patient  education,  and  changes  in  the  administration  and             in outpatient care has shown that these two methods when
             structure of the system itself.                                             applied to hypertensives do not yield similar conclusions, and
                                                                                         that cases must be categorized by severity of disease.
             A key element in initiating  quality  assurance  efforts  in  hos-
             pitals is the establishment of close, positive working relation-            Nurses in skilled nursing facilities in an expanded role pro-
             ships with medical and administrative  staffs  to  insure  that  a          vided through training document patients' treatment plans,
             quality assurance system,  whether  urban  or  rural,  will  be             disease status and daily activities more completely, are
             accepted  and  operational.  A  few  highly  motivated   physi-             better able to assess the total patient's needs and provide
             cians  and  hospital  administrators  might  form  the  nucleus             more appropriate and better quality care.
             of the group designated to establish the system.






                 Quality    Assurance    Projects     Among     Professional             JCAH and Federal Perspective
                 Disciplines and Organizations
                                                                                         Quality assurance activity as a continuing trend in health
                 The presentation  included  programs  to  train  nurses  in  the        care has shifted from voluntary to required.  Assessment
                 development of patient health outcome criteria through sem-             of the actual process of health care delivery and the out-
                 inars using the nominal group technique, and  to  validate  cri-        come of health care services has taken precedence over as-
                 teria  through  seminars  where  outcomes  were   critiqued   by        sessment of structure. Organized quality assurance activity
                 researchers; to computerize  a  reporting  system  using  social        has expanded from the acute hospital setting to the long
                 workers in health  care  to  conduct  research  to  study  their        term care and ambulatory sector and has become more the
                 effectiveness and establish norms for social  work  service             ongoing responsibility of organized external groups than
                 delivery; to develop  standards  and  guidelines  for  reviewing        the function of internal staff committees on an episodic
                 individual certificate of need applications utilizing  a  mathe-        basis.
                 matical model and a panel of experts; to train medical
                 records associates in  audit  procedures,  and  to  use  medical        Major quality assurance issues will be review of additional
                 self-audit to point out needs for continuing education among            nonfederally funded care by PSROS, the need to prepare for
                 an organization of private medical practitioners.                       National Health Insurance, the need for a national strategy
                                                                                         to define problems, address them and establish priorities,
                 Quality   Assurance   Programs    Related    to    Specific             and the need to reduce over-reliance on PSROs as mechan-
                 Diseases                                                                isms to lower costs.

                 Discharge  summaries  were  evaluated  in  order  to   determine        PSROs should function as coordinating nuclei for community-
                 changes in blood pressure levels of  hypertensive  patients             wide quality assurance systems which include representatives
                 resulting from educational programs;  it  was  found  that  pre-        from all health care disciplines and reflect needs and practices
                 sent techniques for educating  such  patients  have  proved             of the locality.
                 successful  only  temporarily  and  that  better  methods   must
                 be sought,

                 Through  the  conduct  of  medical  audit  for  a   hypertension
                 registry, established criteria provided to hypertension  clinics
          21     are used to reallocate  resources  according  to  the  needs  of
                 patients.

                 Setting standards for data  collection  and  providing  perform-
                 ance feedback have  led  to  improved  patient  care  and  a  50
                 percent  drop  in  in-hospital  mortality  from  acute  coronary
                 disease.


                 In an area of high incidence of  respiratory  problems  and  con
                 siderable  patient   movement   between   hospitals,   pulmonary
                 care standards and a computerized  inter-link  system  have  led
                 physicians to use findings of  tests  completed  at  other  hos-
                 pitals and to avoid repetition.

                 Small rural hospitals  with  few  trained  laboratory  personnel
                 formed a  preceptorship  system  stressing  feedback  to  health
                 care professionals  on  how  their  performance  met  standards.







                                 WORKSHOP PARTICIPANTS


                                 QUALITY ASSURANCE PROGRAMS


                                 Current PSRO Activities


                   Moderator:



                                 Samuel R. Sherman, M.D., Director, Quality of Care Program, California Regional
                                 Medical Program, 7700 Edgewater Drive, Oakland, California 94621
                     Speaker:

                                 Edward Zivot, Executive Director, California PSRO Support Center, 215 Market Street,
                                 Suite 1301, San Francisco, California 94105


                                 Hospital Quality Assurance Programs


                  Moderator:
                                 Leslie Sandlow, M.D., Vice President for Professional Affairs, Michael Reese Hospital
                                 and Medical Center.. 29th Street and Ellis Avenue, Chicago, Illinois 60616


                    Panelists:

                                 Quality Assurance in Community Hospital                                       22
                                 William P. Nelson 111, M.D., Associate Professor of Medicine, Veterans Administration
                                 Hospital, Albany, New York 12208

                                 Rural Hospital Quality Assurance Consortia
                                 John T. Rorex, Director, Health Planning, White River Planning & Development District,
                                 P. 0. Box 2396, Batesville, Arizona 72501

                                 Health Care Review in Rural Hospitals
                                 Robert H. Barnes, M.D., Director, Health Care Review Center, 909 University Street,
                                 Seattle, Washington 98101

                                 Quality Assurance Workshop and Follow-up System
                                 Samuel R. Sherman, M.D.

                                 Evaluation of Nurse Practitioner in a Hospital Emergency Room Department
                                 Glen E. Hastings, M.D., Associate Professor of Medicine, University of Florida, Center
                                 House Inn, 1400 N.W. ldth Avenue, Suite 15F, Miami, Florida 33136


                                 Non-Hospital Quality Assurance Programs
                 Moderator:      Robert G. Rowland, Coordinator, Quality of Care Program, California Regional Medical
                                 Program, 7700 Edgewater Drive, Oakland, California 94621

                                 Efficacy of Tracers in Ambulatory Care
                                 Ira Gabrielson, M.D., Chairman, Department of Community and Preventive Medicine,
                                 Medical College of Pennsylvania, 3300 Henry Avenue, Philadelphis, Pennsylvania 19129






                              Quality Assessment Through Outcome Analysis
                              Fred Nobrega, M.D., Director, Health Care Research Unit, Mayo Clinic, Rochester,
                              Maine 55901
                              Improvement of Quality of Care in Skilled Nursing Homes
                              Patricia Wihtol, R.N., Nursing Instructor, 16 Crescent Ave., Scituate, Massachusetts
                              02066

                              Patient Care Audit in Skilled Nursing Facilities
                              Lila Maples, R.N., President, California Nurses Association, 2172 DuPont Drive,
                              Suite 215, Irvine, California 92664

                              Quality Assurance in Home Care
                              Rita Berkoben, Project Director, Quality Assurance Project, Pennsylvania  Assembly  of
                              Home Health Agencies, 200 Meyran Avenue, Pittsburgh, Pennsylvania 15213

                              Professional Disciplines and Organizations

              Moderator:      Kay Horswill, R.N., M.S., Nursing Coordinator,  Wisconsin  Regional  Medical  Program,
                              5721 Odana Road, Madison, Wisconsin 53719

             Panelists:       Patient Outcome Criteria by Peer Review
                              Connie Keyes, R.N., M.S., Project Associate and Clinical Nurse Specialist,  6622  May-
                              wood Avenue, Middleton, Wisconsin 53562
                              Computerized Social Work for Patient Care Project
                              Miriam Birdwhistell, A.C.S.W., Ed.D., Chairman, University of Virginia Medical
                              Center, Division of Social Work, Box 275, Charlottsville, Virginia 22903
        23                    Developing Standards for Specialty Care
                              Skip Habich, Associate Coordinator, New Jersey Regional Medical Program, 7 Glenwood
                              Avenue, East Orange, New Jersey 07017

                              California Medical Records Quality of Care Project
                              Cynthia A. Boudreau, R.R.A., Member, CMRA Committee on Patient Care Audit,
                              250 Masonic Avenue, San Francisco, California 94118

                              Medical Association's Voluntary Self-Audit
                              Daniel Hamaty, M.D.,Director, Connecticut Medical Institute,  90  Sargent  Drive,  New
                              Haven, Connecticut 06551

                              Specific Diseases and Procedures

           Moderator:         Edward W.  Francisco,  Ph.D.,  Coordinator,  Northern  New  England  Regional  Medical
                              Program, Executive Square, 346 Shelburne Road, Burlington, Vermont 05401
           Panelists:         Assessment of Quality of Care for Hypertensives
                              Gerald Wolf, M.D., Associate Professor of Radiology and  Pharmacology,  University  of
                              Nebraska, 42nd Street and Dewey Avenue, Omaha, Nebraska 68105
                              Use of a Hypertension Registry in Medical Audit
                              Fredric L. Coe, M.D., Director Renal Division, Michael Reese Hospital, 29th Street and
                              Ellis Avenue, Chicago, Illinois 60616
                              Coronary Care Management Criteria
                              Richard E. Bouchard, M.D., Associate Professor of  Medicine,  University  of  Vermont,
                              Burlington, Vermont 05401







                            Laboratory Standards
                            Clay Elting, Allied Health Specialist, Washington/Alaska Regional Medical Program,
                            1107 N.E. 45th Street, Suite 500, Seattle, Washington 98105

                            Pulmonary Care Standards
                            Tom Pace, Coordinator, Quality of Care Programs, Intermountain Regional Medical
                            Program, 540 Arapeen Drive, Suite 201, Salt Lake City, Utah 84108

                            Future of Quality Assurance Programs


          Moderator:        Samuel R. Sherman, M.D.


          Speakers:         John D. Porterfield, M.D., Director, Joint Commission on Accreditation of Hospitals,
                            875 North Michigan Avenue, Chicago, Illinois 6061 1

                            Leslie Ford, M.D., Division of Peer Review, Bureau of Quality Assurance, 5600 Fishers
                            Lane, Rockville, Maryland 20852














                                                                                                                      24

















                   IMPLEMENTATION       OF       PUBLIC        LAW        93-641









                           With inflation in the health industry rising 50 percent faster than the federal economy panel-
                           ists saw governmental intervention in the market place as inevitably growing, and the Health
                           Planning and Resources Development Act of 1974 as perhaps a fresh attempt to solve a
                           stubborn problem.  Intending to combine health planning as a tool of regulation to achieve
                           effective cost controls and more optimal distribution of health services, the law poses diffi-
                           cult and complex choices.


               Health  Systems  Agencies  are  being  developed  as  both  advo-        Control over much of the health care system in the United
               cates of  areawide  health  needs  and  enforcers  of  Department        States is passing through this legislation into the hands of the
        25     of Health Education  and  Welfare  policy.  In  its  administration      Secretary of DHEW, allowing him to exert whatever measures
               of the legislation DHEW will  try  to  satisfy  Congress,  on  whom      he finds necessary to achieve the purposes of the law. His
               it depends for funding;  similarly  the  HSAs  will  implement  the      power over state agencies and how they operate, through the
               law as satisfactorily to the department as possible.  But  in  this      withholding of Public Health Service funds from states deemed
               process it was felt there is likely to be a blunting or a disregard      to be implementing the law too slowly, or inappropriately, is
               of the legitimate needs for health services  arising  from  local        immense; it usurps traditional prerogatives of state government.
               communities.
                                                                                        If the state fails to meet the requirements of the law and of
               The Congressional  charge  to  the  HSAs  is  much  more  sharply        the Secretary within a specified time, then the Secretary may
               focused  than  it  was  for  Comprehensive  Health  Planning  Agen-      withhold all federal health funds appropriated under the Public
               cies; statutory authority will  be  much  greater.  Selection  of        Health   SeIrvice and related acts from use within that state.
               HSA  board   members   with   mandated   representation   quotas,        This could involve a significant sum of funds since this group
               should  include  "the  yeast  of  at-large,  maverick   consumers        of federal acts includes all federal funds for research grants,
               and  nonestablishment  consumers"  to   forestall   provider   or        medical education, nurse training, allied health, mental
               establishment  domination  of  board  direction.  The  very   ex-        health, mental retardation, alcoholism programs, facility
               plicitness of the law and  its  inherently  contradictory  elements      construction, support funds for Departments of Public
               may  overwhelm  the  health  planning  process  and  cripple  its        Health, and other related programs. These funds may not
               operation.                                                               only provide support for state activities, but also go to
               Public Law 93-641 evokes  a  particularly  skittish  reaction  from      universities, local government and some private non-profit
               hospitals, since they receive such a large share  of  the  health        corporations.
               care dollar and thus  feel  most  vulnerable  to  new  regulatory        State powers are further eroded through Public Law 93-641
               procedures, The law pumps planning  in  at  "too  late  a  stage"        by the mandate that acceptable certificate of need legisla-
               and gives  the  impression  that  regulation  pre-empts  planning        tion must be passed before a state government can enter
               rather  than  being  an  accompaniment  to  it.  While  hospitals        into an agreement with the DHEW Secretary. Providers
               may not have a cohesive  stand,  the  new  law  nevertheless  en-        believe that such legislation must be linked with rate-setting;
               genders widespread dissatisfaction. It does  not  regulate  in  a        the rate-setter ought not be an important major purchaser
               simple, easy  to  understand  manner;  some  of  its  regulations        of health care, as both state and federal governments are.
               cannot be  equitably  administered;  others  cannot  be  adminis-        Thus, there is a glaring conflict of interest in the new law
               tered at all. Perhaps sixty per cent of the federal cost  control
               effort is likely to be directed at hospitals, yet they  may  have        permitting the Secretary of DHEW to be both a regulator
               no more than  one  or  two  representatives  on  an  HSA  govern-        and a purchaser of health care services, leading to captured
               ing board.                                                               regulation in the hands of vested interests.







                  Finally, although it appears that a majority of the HSAs             June 30, 1976, there is no clear commitment to fund the
                  now being developed to fulfill the first purposes of the             program at levels sufficient to begin realistically to achieve
                  legislation will have received conditional designation by            the ends of the new law.



























                                                                                                                                                26




















                                             IL'i








                                     WORKSHOP PARTICIPANTS


                                     IMPLEMENTATION OF P.L. 93-641

                                     Planning


                   Moderator:        Gary Fink, Associate Coordinator, Iowa Regional Medical Program, Oakdale Hospital,
                                     Oakdale, Iowa 52319

                   Panelists:        Progress Report on Health Systems Agencies
                                     Collin Rorrie, Ph.D., Assistant to the Associate Director, Health Resources Planning,
                                     Health Resources Administration, 5600 Fishers Lane, Rockville, Maryland 20852

                                     Functions, Staffing and Board of Health Systems Agencies
                                     Steve Sieverts, Special Consultant, American Hospital Association, One Farragut Square
                                     South, Washington, D.C. 20006

                                     Health Systems Agencies: Advocates of Community Needs or Enforcers for
                                     DHEW
                                     Darwin Palmiere, Ph.D., Dean, Human Resources, State University College, Brockport,
                                     New York 14420



                                     Regulation


                   Moderator:        Paul D. Ward, Executive Director, California Regional Medical Program, 7700 Edgewater
                                     Drive, Oakland, California 94621

      27           Panelists:        Theory and History of Regulation
                                     Henry Zaretsky, Ph.D., Director of Research, California Hospital Association, 925 "L"
                                     Street, Suite 1250, Sacramento, California 95814

                                     Regulatory Aspects of P. L. 93-641
                                     Paul D. Ward

                                     Health Facility's Reaction to P.L. 93-641 Regulation
                                     Robert Derzon, Director, Hospitals and Clinics, University of California Medical Center,
                                     San Francisco, California 94143



                                     Health Resource Development


                   Moderator:        Charles D. Holland, Director, West Virginia Regional Medical Program, 258 Stewart Street,
                                     Morgantown, West@Virginia 26506

                   Panelists:        Title XVI Replaces Hill-Burton Agencies
                                     Edward N. Duncan, Director, Facilities Development, Bureau of Health Planning and
                                     Resources Development, 5600 Fishers Lane, Room 12-1 1, Rockville, Maryland 20852

                                     Resource Development by the State and by the Health Systems Agency
                                     Charles D. Holland

                                     Resource Development and the Federal Government
                                     Richard L. Russell, Chairman, Developmental Fund Work Group, Bureau of Health
                                     Planning and Resources Development, 5600 Fishers Lane, Room 1 1A-46, Rockville,
                                     Maryland 20852























             HEALTH CULTURAL AWARENESS


             Health Cultural Awareness
             Failure of health planners to take into consideration varying          07017), the session included presentations by a multi-cultural
             cultural backgrounds often leads to health legislation and pro-        panel of experts, representatives of a variety of health pro-
             grams that neglect the very people they were designed to               grams and agencies, both public and private.
             serve. Usually such people are of ethnic minority groups
             whose approach to health problems differs widely from                  Panelists related their personal experiences and cultural dif-
             that of the majority,                                                  ferences and similarities in terms of ethnically traditional
                                                                                    as well as current and projected health needs. Viewpoints
             The Health Cultural Awareness discussion was conducted in              specifically represented included Island Blacks, Chinese,
             response to a request from Regional Medical Program coor-              Mexican-Chicano, American Indian and Puerto Rican. Pan-
             dinators to consider the needs of these minority groups.               elists called for a plan of action that would incorporate
             Sponsored by the Center for Human Resources Planning and               ethnic and cultural considerations appropriately into        28
             Development (7 Glenwood Avenue, East Orange, New Jersey                national health legislation.












                                    NATIONAL ASSOCIATION OF REGIONAL MEDICAL PROGRAMS







                                              Board of Directors

                                              John R. F. lngall, M.D., Chairman,             James W. Culbertson, M.D.
                                              Buffalo, New York                              Memphis, Tennessee

                                              J. Gordon Barrow, M.D.                         Robert W. Lawton
                                              Atlanta, Georgia                               Cranston, Rhode Island

                                              Robert W. Brown, M.D.                          Benjamin Morgan
                                              Kansas City, Kansas                            Buffalo, New York

                                              Charles W. Caldwell                            Donal R. Sparkman, M.D.
                                              Oakdale, Iowa                                  Seattle, Washington

                                                                                             Paul D. Ward
                                                                                             Oakdale, California



          29









                             Program Committee
                             J. S. Reinschmidt, M.D.,                   J. R.  Gallagher
                             Oregon Regional Medical Program            Iowa Regional Medical Program
                             Harry Auerback                             Charles D. Holland
                             Illinois Regional Medical Program          West Virginia Regional Medical Program
                             J.  Gordon  Bar 'row, M.D.                 John R. F. lngall, M.D.
                             Georgia Regional Medical Program           Lakes Area Regional Medical Program

                             William Boquist                            Robert Miller
                             California Regional Medical Program        Lakes Area Regional Medical Program

                             Donald G. Brekke                           Benjamin Morgan
                             South Dakota Regional Medical Program      Lakes Area Regional Medical Program

                             Robert W. Brown, M.D.                      C. E. Smith, Ph.D.
                             Kansas Regional Medical Program            Mountain States Regional Medical Program

                             Charles W. Caldwell                        Paul D. Ward
                             Iowa Regional Medical Program              California Regional Medical Program

                             James W. Culbertson, M.D.                  Roger J. Warner
                             Memphis Regional Medical Program           Arkansas Regional Medical Program
                             Gary Fink                                  Charles White, Ph.D.
                             Iowa Regional Medical Program              California Regional Medical Program                                  30






                                                                                         Public Information Committee

                                                                                         William Boquist, Chairman
                                                                                         California Regional Medical Program

                                                                                         Edna Carroll
                                                                                         Bi-State Regional Medical Program

                                                                                         Frederick E. Frazier
                                                                                         Missouri Regional Medical Program

                                                                                         Gerald N. Gold
                                                                                         New Jersey Regional Medical Program

                                                                                         Jim Robe
                                                                                         Florida Regional Medical Program

                                                                                         Sylvia Sterne
                                                                                         Louisiana Regional Medical Program








                                                                                    1975










          National Association of Regional Medical Programs, Inc.                                                 Non-Profit
                                                                                                                U. S. Postage
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