0                                                              0                                                              0









                                   REGIONAL MEDICAL PROGRAMS SERVICE
                       SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                    (A Privileged Communication)



                Al.@]iANY Rl-"GIONAI@ MEDICAL PROGRAM                  RM 00004 7/70.1
                Albany @,tedical College of Union                      June 1970
                 University                                            Review Committee
                47 New Scotland Avenue
                Albany, New York  12208

                    ram Coordinator:  Frank M. Woolsey, Jr., M. D.


                Requested
                Program
                Period               Ist Year       2nd Year       3rd Year       TOTAL
                Direct Costs         $61,700        $61,730          -0-            $123,430
                Indirect Costs        17,831         18,243         .-O-              36,074


                TOTAL                $79,531        $79,973          -0-            $159,504
                I-IISTORY:  The Albany Regional Medical Program received a planning award
                          in June 1966,  and  its  first  operational  award  in  April  1967.
                The current annual level  of  support  is  $1,534,208  total  costs:  $993,951
                for core and $540,257 for  eight  projects.  See  History  Supplement  at  the
                end of this Summary Sheet.
                After two years operating experience,  a  renewal  request  for  the  entire
                program (at that time, Projects #1, 2, 4, 5, 6,  7,  12,  13,  and  Core)  was
                reviewed by May  1969  Council.  The  reviewers  were  concerned  about  the
                progress of the Region: it  appeared  not  to  have  developed  much  beyond
                the initial continuing education efforts with concentration of activity
                at the Albany Medical Center; the Coordinator and the Department of
                Post-graduate Education seemed to dominate the planning, review and
                implementation process: and the Region lacked plans for phasing out
                support of present activities.  A subsequent site visit in May, 1969,
                conveyed the reviewers misgivings to the Region.
                Recommendations of the August  1969  Council  on  the  renewal  package  and
                one supplemental operational project were designed Lo communicate the
                reviewers' concerns to the Region and provide time for program realignment
                e.g.,curtailed one year  support  was  recommended  for  some  projects  about
                which there were concerns, but five vears! full funding was recommended
                for the supplemental operational project for a community leadership






          AI,BANY                            -2-                RM 00004  7/70.1
          Regional Medical Program

          program.  The Council felt  that  any  future  application  for  funds  must
          indicate  that the ARMP has come to grips with its problems.
          Subsequently,  March  1970 Council recommended that Project #17,
          comprehensive  Communitv  Stroke  Program,  be  returned  for  further  planning
          and  revision.  It was  noted,  however,  that  the  stroke  program  proposal
          represented  a welcome  break  from  the  Albany-based  continuing   education
          pattern  which had been established.
          PIZESENT API'LICATION:  This  application  contains  a  proposal  for  renewal
                                  support for Project #7- Community hospital
          Coronary Care  Training  and  Demonstration  Program,  which  was  initiated
          ir April 1967. The  project  is  presented  in  two  parts,  #7A  and  #7B,
          which  are  discussed  separately  below.  The  application  also  includes
          a request for Litil)-Dlemental funding of a new  activity:  Proiect  #18  -
          Albany Regional Libra     Service               rovement  of  Library   Services
          and Resources in Co      iitv Hospitals. Direct  costs  only  Ere  noted  in
          the project descriptions below.

          Project #s 7A (R) and 7B (R)
                                            and  Demonstration   Programs.   August   1969
          Council   and the site visitors noted  that  the  original  intent  of  these
          two satellite centers to  provide  CCU  training  for  nurses  from  nearby
          hospitals had been somewhat altered in practice, and the project appeared
          Lo be  concentrating  on  training  their  own  personnel.  Consequently,  onl.v
          One vear's additional  funding  was  recommended  with  any  future  support
          dependent on the number of trainees from other area hospitals.          The
          funding history of these two activities is as follows:
                                              3OM5    7/lt@-9/30/69    1-0/i/69-9/30/70
          llroject  #7A                $27,705          $23,435          $17,940
          Project   #7B                  27,705          24,485           18,990
          Ilroject  #7A (R) -  Community  Hospital  Coronary  Care  Training  and      ue,,Lted
                             Demonstration Program, Berkshire Medical               First Year
                             Center,  Pittsfield,  Massachusetts.  This   is   a    $17,9140
          request  for  continued  partial  support  to  professional  personnel
          i.ii proportion to their  involvement  in  the  educational  component
          of coronary care activities at the Berkshire Medical Center.
          l@'ar.l.v in Albaiiy's history, as it became clear that the primary
          C()ronarv care training program at  the  Albany  Medical  Center  (Ilroject
          #6) could not meet the staffing  needs  of  all  hospitals  in  the  Region,
          a decision was made  to  establish  secondary  centers  on  a  subrei,ional







                Al, BANY                         -3-                   RM 00004  7/70.1
                Regional Medical Program


                '-)asis. The function of these facilities would be to share  with  the
                primary center the responsibility of training health personnel in
                intensive coronary care, to serve as a subregional demonstration  unit.
                and to relate in appropriate fashion with the  Albany  Medical  Center
                on one hand and the smaller community hospitals on the other.  -It
                was in this atmosphere that the Berkshire Medical. Center developed
                a subregional coronary care program early in 1968.

                In order to effectively implement the program, it was decided  that  a
                minimum of three physicians contribute at least ten percent  of  their
                time to training, educational, and consultative activities.  Similarly,
                three nurses were to devote one third of their efforts to these
                activities. The services of one half-time secretary  were  also  deemed
                necessary.

                To date, 82 nurses have been trained at the Center, 73  from  the  Center
                itself, 8 from other community hospitals, and one from an extended care
                facility. Of these nurses, 33 received training in  the  three  25-hour
                courses conducted during 1969, and five were from outside  Bc-!rkshire
                Medical Center.  Future plans include involving more nurses from smaller
                liospitals,(at the time this application was prepared, eight nurses from
                other hospitals were enroll-ed for the next scheduled  course)  arranging
                a number of advance seminars at the Albany Medical Center,  adding  the
                ROCOM Ifultimedia Instructional System to the existing  coronary  care
                programi and cooperating with the Tri-State Regional. Medical  Program
                in several joint ventures. These latter  include  a  proposed  Fellowship
                in Cardiology at the Berkshire Center and a system of  telephonic  ECG
                monitoring between the Center and a hospital  and  several  institutions.

                Second Year:  $17,940                     Third Year:  None
                Project #7B (R) - Community Hospital Coronary Care Training and      Requested
                                  Demonstration Program, Vassar Brothers             First Year
                                  Hospital, Poughkeepsie, New York.  This            $18,990
                request is nearly identical to that made for Project #7A above,
                the single difference being that there are only two  nursing  positions
                in this proposal.

                The Vassar Brothers hospital was another of the sites selected  to  be
                one of the secondary, subregional coronary care centers described
                above.

                AI)proximately 90 nurses have participated in the program so far,  and
                again, the vast majority were on staff at  Vassar  Brothers  hospital.








                                         -4-                 RM 00004  7/70.1
        Al,liANY
        Regional Medical Program

        (In 1968, six from other hospitals in the Poughkeepsie area partici-'
        pated.)  Of these 90 nurses, 19 received training during 1969, and the
        application states that although an effort was made to involve partici-
        pants from other area hospitals, no candidates were  made  available.
        In the future, courses will be extended to other ancillary.personnel
        such as LPN'S, efforts will be made to,encourage  more  participation
        ,by smaller coummunity hospitals, and along these lines, it has  been
        suggested that the ROCOM system be used in these  smaller  hospitals.
        There will also be a series of advance seminars at the Albany Medical
        Center for nurses chosen for their leadership potential at boththe
        educational and service level.
        Second Year:  $18,990                     Third Year:  None
        Project #18 -                       rv Service Proiect -  Improvement  Requested
                                             d Resources in     unit           First Year
                                             a result of repeated requests      $24,770
        by hospital  ad                     stance in training library personnel
        and partly  due to the findings of a somewhat limited survey of library
        facilities  and personnel, AMV has concluded that there is an urgent
        need for improvement in these areas. To meet this  need,  the  Region
        has developed a program that is to be implemented in two phases.  The
        first phase will concentrate on training existing community hospital
        personnel in the basic essentials of medical librarianship, and it is
        for this phase that support is being requested in the present applica-
        tion.  The second phase, which is to be initiated two years after the
        start of Phase 1, will attempt to establish a cooperative medical library
        network within the Region for exchange of materials and reference service
        and to provide a professional librarian to coordinate and supervise the
        library network in the Region.
        During Phase I, hospital administrators and executive  committees  of
        medical staffs will be informed of the nature of the project and will
        be given the opportunity of sending one individual to the nearest
        training center.  They will be encouraged to seek candidates with
        bachelor degrees to fill vacancies that occur in hospital libraries.
        The hospital administrator sending a candidate into the program will
        also be encouraged to declare his institution's willingness to purchase
        a minimum core collection of library materials and provide a budget to
        insure its upkeep and servicing.
        The Phase I proposal is for two training centers to be established within
        the geographical bounds of the Albany region, Ellis Hospital located at






                 ALBANY                            -5-               RM  00004  7/70.1
                 Regional Medical Progtam


                 Schenectady, New York and Will Rogers Memorial Hospital, Saranac
                 Lake, New York.
                 Each training course will,be given over a period  of  40  hours.  It
               .may be given in a one-week. program or it may take place over  a  -.Longer
                 time, interval depending on circumstances. There  will  be  between  four
                 and six students in each course.

                 As for evaluation, trainees will be examined before  and  after  the
                 course to determine the amount of knowledge acquired  and  again  six
                 months later to measure the degree of  retention.  The  hospitals  that
                 have had personnel trained through this project will be surveyed by
                 the project coordinator to determine the type of  book  and  journal
                 collections and to evaluate the amount and quality of services
                 rendered to the staffs of these  hospitals.  Finally,  and  in  anticipa-
                 tion of Phase II, all community hospital  libraries,  regardless  of
                 whether they have sent people throughthe program, will be requested
                 to maintain certain minimal statistics including the  number  of  books
                 and journals in the library, the number and  types  of  items  circulated
                 in six months and one year, the number of reference questions received
                 and interlibrary loans made in the same time period.  This data collec-
                 tion would begin with the start of Phase I.

                 ARNP is aware of a number of other similar efforts  in  varying  stages
                 of development within the Region.  These include New York State Inter-
                 library Loans (NYSILL), Capital District Library Council, State
                 University of New York Biomedical Network, New York  and  New  Jersey
                 Regional Medical Library, and several  others.  The  Region  states  that
                 the present proposal does not duplicate any of  these  other  programs.
                 More detailed information on Phase II will be submitted  at  a  later
                 date,, but at present, it can be said that it intends to make available
                 virtually all learning modalities:  books,  journals,  tapes,  films,
                 records, etc. Services that are to  be  provided  include  reference,
                 interlibrary loans, bibliographic and technical  assistance,  and  rap:kd
                 communications.

                 Second Year:  $24,800                    Third Year:    one








                                                                 RM 00004 7/70.1
                                         -6-
        ALBANY
        Regional Medical Program

                                      HISTORY SUPPLEMENT

                                                           Current Yearl@
                                                           Support or          Initiation
        PROJECT            Project Title                   Status (DCO)        Date
        1          Two-Way Radio Communication System      $143,975            4-1-67
        2          Community Information Coordinator       Now included        4-1-67
                                                           in  Core

        3          Communication and Information           Disapproved
                   Activities

        4          Postgraduate Instruction
                   Development Panel                       $80,745             4-1-67

        5          Community Hospital Learning
                   Centers                                 $111,082            4-1-67

        6          Albany'Medical Center Coronary
                   Care Training and Demonstration
                   Programs                                $71,746             4-1-67
        7          Community Hospital Coronary Care        $36,930             4-1-67
                   Training,and Demonstration Program
        8          Regional Rehabilitation Team            Disapproved

        9          Training Program for Physical
                   Therapy Aides                           Not Funded by Region

        10         Expansion of Albany County
                   Tumor Registry                          Not Funded by Region
                   Development of Computer Utilization     Disapproved

                   Intensive Cardiac Care Unit -
                   Herkimer                                $7,207              4-1-67
        1-3        Schenectady Cancer Coordinator          $5,000              1-1-68
        114        Core                                    $712,094*

         *IL should be noted that the core bud2et included $60.020 in personnel costs
          for partial support of the planning and development stage of the Albany North
          End Community Health Center.  The Health Center project is OCHP - approved
         but not funded.  As  soon  as  OCHP  money  is  available,    support will end.








          ALBANY                             -7-               RM 00004 7/70.1
          Regional Medical Program



          15           Establishment of Regional Cancer      Disapproved
                       Program

          16           Development of Community
                       Leadership Program                    $9,030              10-1-69

          17           Comprehensive Community               Returned for revision
                       Stroke Program













































                                                                            GRB-5/19/70






                                                     SUi4MARY OF
                                                                                                                0,
                                                              JUiiE  1.970


                                                         ALBANY                      MEDICAL           PROCIIA.14
                                                                       @l 00004    7/70.1

                                           FOR CONSIDERATION BY JUT:,Y  1970 ADVISORY CO@ICIL

                     General:      The      Committee      recalled      its      lengthy      discussions       of       a       year       ago
                                     which      were       occasioned       by       the       Albany       Regional       Medical.       Prograni's
                     continued       concentration       of       efforts       in        continuing        education        throtlch        the
                     Albany      Medical      Center.      It       was       noted       that       the       Community       Hospital       Coronary
                     Care      Training      and      Demonstration      Program,      which      is       presented       as       Project       l@-s
                     7A(R)      and      7B(R)      in      the      present       application,       represented       an       effort       toward
                     r(@gionalization      of      R@IP      activities,       and       approval       of       renewal       support       was
                     -ii  @c@i-ni-nei-ided  on  those  grounds.    The Albany Regional  Library  Service Project
                     f@      @,7hich      supplemental       funding       is       being       requested,       was       not       considered
                     v@      enough  developed  to warrant  approval  at                                     time;        the         Committee
                            @,,3tecl  revision.

                     Project Yi's  7A(R)  and  7B(R)  -    o@Tmn n@ity                                          I
                                                                                         il2s2_tal     g2r      narv      Care      Trai.ni-,IP,
                                                                                                                2
                                                                       and  Demonstration Pro@rraitis.

                     Ln@a ( i@:        These  two  satellite  coronary  care  training  programs  in
                                        community         hospitals,          Project          7A          (Pittsfield.,          Massachusetts)
                     and       Project'7B        (Poughkeepsie,        Now        York),        were        discussed        together        because
                     of  their marked  similarities.    It was  noted  that  there appears  to  be
                     some      increase      of      trainees      from       the       area       surrounding       the       Berkshire       Medical
                     Center  (although  still  rather minimal)  since  Committee reviewed  t  j@,9
                     project     a     year     ago,      but      very      little      involvement      of      those      hospitals      ill
                     the Poughkeepsie area  (but with  expectations  for  future  involvement
                                                        licaLioii).      This      prompted       a       discussion       as       to       whether
                     expressed  in  the  app
                     such     a     slight      increase      in      the      number      of      trainees      from      other      hospitals
                     was      sufficient       justification       for       further       funding       of       the       two       projects.
                     It    was    pointed    out     that     one     of     the     primary     problems     of     the     Albany     P,@I.P     has
                     been     its     abysmal     lack     of     involvement      outside      of      the      city      of      Aibaiiy      itself
                     and       that       these       projects       represent        definite        regiortil-izatioii        efforts;        that
                     these. activities  evidence  an  interest                               the                care        world        (albeit
                     education);  that  efforts  are  being made  to rc@d,-@                                 @@lie         apparent         resistance
                                                                                                             1,
                     on     the     part     of     other     hospit@.Is     i,ii  the ar,,@a  to  I          ;@o  each  of  these  two
                     coil.imilriity  cc-nt-c,.rs  for  training  of  their  personi-!,'@                      .,iiid      that      these      programs
                     are working  to  break  down  the  seeming  iriLc-,rprof@-                              .formal      ai)i.iiiosity       toward
                     this  outward  expansion.   Many  Committee                                                  the modest                        of
                     money  requested  :co2-  these  two projects                                   got  the Re@,ioi:k  over                  hu.,,,i
                                                                                                                                                   P.
                     It    was    also    iiote(.t    that    the    costs     of     the     programs     will     be     absorb(-et     at     the
                     local-  level-  at  the  end  Of  tl,7o  additional.  years  of  support.

                     R e c   -@i eri cl t i, c)-,i In  light  Of  the ,ti)o-,;e                              the  Cc)i,,siiit:tce r,@,coiii,.@ic,.nclcd
                                                  Appro\tal    I    i@)    the    finite    and    aiiiouT-it:
                     two




               ALIM-INY  Vegloiiai  kleclicai  Program               -Z. -               IWI VVUV'E /tiv.-L

                           that   a   mechanism   be   developed   to   provide    encouragement    for    the
                           involvement of personnel of community hospitals in the two
                           training centers, and

                     2.    that   the   Region   clearly   specify   that   the   training    program    will,
                           be continued beyond the project period without additional
                           support from PL%IP.

               DIRECT COSTS ONLY:         Project           Ist Year        2nd Year      3rd Year
                                            7A(R)           $17,9/4-0       $17,94o           0
                                            7B(R)            18,990          1.8,990          0

               There were two dissenting votes.

               Project Y[18 - Llb
                                    @n
                                                                 Ser-vi.ce Prolect - IInDrovemeiit of
                                 LibraL.y.13-.r@v-Lcc,,@l  d  Resources  in  Coinmu.nitv   I-Tosi-)i.tals.

                             The  Co,@nmi-ttee  was   hampered   in   its   evaluation   of   t-hi.s   project
                             by the lack of basic information as to the number of                      courses
               planned and any supporting data documenting the availability of                         students.
               It was noted that there appeared to be little transition from data glc@an,ed
               through a survey of library needs and the proposed solutions to pro  e.-i.-ns
               which are contained in this project proposal.  Specifically, altl-iou.@.@ll
               trained  personnel  does  not  surface  from  the  survey  as   a   primary   need,   the
               approach  i-s  to  train  personnel  as  a  first  step,,        There   was   also   concern
               about  the  relationship  between  the  budget  iiid   the   Phase   I   proposal.   Almost
               half of the request is for a project coordinator at the Albiny
               College while the training is to be carried out at the Ellis and
               Rogers Hospitals.

               A  National  Library  of  Medicine   technical   review   indicated   concern   as   to
               the  apparent   overemphasis   which   the   project   places   On   training   without
               the important aspects of consultation. a)-id assistance to the librarians
               trained  which  might  be  necessary  to  make  the   system   work.   The   NIM   reviewer
               also  noted  that  the  ippli.catior@  appears  to  propose   the   beginnings   of
               training   projects   in   the   absence   of   any   plan   for    the    long-range    measurement
               of li.])rary and information needs within the Region.

                                                                  pi-i-)iiary ict:i-vitic-@s would be the
               Since one of the project cooi--A
               planning of future projects, the          "revie@@ic@@ics bc-lie-vcd that pertiips the  main
               function that would be sorvc.,@,(1 by the project would be the development Of
               a  greatly  expanded  request  for   library   activities   in   the   Albany   Region.
               In  short,  although  the  Regi.oii  has  collected  data  relative  to   the   hospital.
               library situation, it  was  felt  that  the  3-c-,@tiltii@ig  project:  is  not  adequately
               developed to warrant fun.0i,ng at tiAis time.             It was suggested that the
               project  ]Dt--  returned  for  revision,  pointing  out  the   eie.@Eici-ciici.(@s   ilient i@011,E@Cl
               above,,,      advising thit the Region develop either a  rc!qLi(@st  for  pla-i@).f).in,,,
               for library activities or a request for training                                 If the rc,,vi.si..@@,,i
               is to be a training request, the prc)roF,,il-, in idclitioii f-@                         out the
                              should clearly defi.).-),c,@ on a                                        of
               potential. trainees and the nuTpl)(.,r of                the col-@rses         be
                                     Non--Apl)rov@-I ",-I                   Y@.c@v@l.,sion    adv:Lcc@.




              ALBANY Regional Medical Prograin                  -3-                P\M 00004  7/70.1

              Concl.usions:


                                                .01  Year              02   Year         03 Year

              Project #7A(R)                     $17,94.0               $17,9@@o           0
              Project Y@7B(R)                      18,990                 18,990           0
              Project Y@18                        Non-Approval II         Return for Revision

                 TOTAL                            $36,930                $36,930           0


































                                                                                DRI\IP /GRB
                                                                                7/10/70



















             a                                                             0                                                              0












                           REGIONAL MEDICAL PROGRAMS SERVICE
                SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                             (A Privileged Communication)

        ARIZONA  REGIONAL  MEDICAL  PROGRAM                  RM00055  7/70.1
        University of  Arizona  College  of Medicine         June 1970
        Tucson, Arizona 85721                                Review   Committee

        Program  Coordinator:  Dermont   W. Melick, M.D.


        Re   -,3tcd
        Program
        f-eriod           Ist Year       2nd Year       3rd Year       Total

        Direct Costs     $151,395        $146,053      $150,628        $448,076
        Indirect Costs     33,189         34,786         36,560         104,535



        TOTAL            $184,584        $180,839      $187,188        $552,611

        IIISTORY:  Support for initial   planning in this Region was authorized
         or two years and three months (April 1, 1967 - June 30, 1969),
        $119,045 the first year, $409,108 the second year and $138,095 the third
        period of three months.  During the second year, an application for
        earmarked funds for a Chronic  Pulmonary  Disease  Program  was  disapproved
        by Council (November 1968) with advice  to  revise  and  resubmit.  Due  to
        delays in the review and funding of the Region's operational program,
        the planning period was extended by nine months,  April  I  -  December  31,
        1969 (two separate extensions)  with  additional  funds  totaling  $500,028.

        In May 1969, Council considered the initial operational application.
        As recommended, a site visit was made that same month to study the Region's
        operational capability.  The  application  requested  support  for  renewal
        of core staff activities and six projects.  Two  of  the  projects  were  in
        the medical library field, one for  continuing  education  of  nurses,  one
        for recruitment and utilization of social service manpower  one cardiopul-
        monary resuscitation training and one revision of the previously submitted
        chronic pulmonary disease program.  The site visit team was greatly
        concerned about the dominating needs of RMP in Phoenix and peripheral
        areas, and the contrast in the Region's  plans  to  concentrate  its  head-
        quarters near the Medical School intucson.      It was also  believed  that
        the evaluation capability of the Region should be strengthened by
        acquiring the services of a specialist.  Impressions with staff leadership
        were favorable.  The team believed that there was adequate evidence
        that the Region was ready  to  assume  operational  status.  Although  some
        major problems had hindered development of the Region's program, the
         I- itors were convinced that further planning  would  not  have  increased
        the capacity to implement an operational program.
   *v s





          ARIZONA Regional Medical           -2-                   RM00055  7/70.1
            Program


          As recommended by Council during the  August  1969  meeting,  $795,406
          (d.c.o.) was awarded for support  of  the  operational  program.  This
          action excluded the  cardiopulmonary  resuscitation  training  project
          which was deferred pending further study and policy decision.     The
          Council recorded its interest in observing this Region's progress
          in dealing with the problems of delivery of health care to the people
          of this state, particularly the widely  dispersed  rural  population  of
          American Indians, Mexican-Americans, and  migrant  workers,  and  others
          not being served.
          During the August 1969 meeting, Council  also  considered  the  Region's
          first supplemental operational application  for  support  of  three
          continuing education projects:  Education In Coronary Care; Community
          Education for Nurses; and  Long-Term  Education  for  Nurses.  Council
          recommended disapproval with advice  to  resubmit.  Reasons  for  this
          action included: 1) absence of coordination  between  the  three  projects;
          2) lack of medical school involvement;  3)  inadequate  physician  partici-
          pation; and 4) weakness in ob  ectives,  curricula,  and  evaluation.  With
          regard to the long term education project,  the  reviewers  also  believed
          there might be some overlap with the regular Master's Program in-
          Medical Surgical Nursing offered in Tucson.

          Following the evolvement of a policy by Council during the December
          1969 meeting, the Region appropriately revised the "Cardiopulmonary
          Resuscitation Training" project,  including  strengthening  the  evaluation
          component. Although approved, funding  status  has  not  been  determined.
          Council alto considered a new supplemental request for support of a
          "Nutrition Care Program for Heart, Cancer,  Stroke,  Diabetes  and  Related
          Diseases" project.   Recommendation:   Return for revision  (with  the
          suggestions of the Review Committee).

          PRESENT APPLICATION:   In light of the August 1969  disapproval  of  three
          Continuing Education Training projects,  and  Council's  suggestions,  the
          Region redeveloped a program for coronary  care  training  which  will
          ultimately involve five projects.  Two of these are submitted for funding
          consideration.  The remaining three, still in development to be submitted
          later, deal with 1) outreach continuing education for nurses and
          physicians; 2) public information and education; and 3) continued
          education for nursing personnel in the Tucson area.  The Region believes
          that the projects now meet all the suggestions by  the  Council  and  will
          provide basically needed education and consultation services.

                                                                           First Year
          Project #11 - Continuing Education Program for Nurses             $76,583
          Submitted by St. Joseph's H ospital, this is a project  to  be  centered
          in the Phoenix metropolitan area.    In planning the  program,  the






         ARIZONA Regional Medical               -3-                 RM00055 7/70.1
           Program



         applicant was assisted by an Advisory Committee, membership which
         included representatives of appropriate agencies including the  Region
         and the University of Arizona College of Medicine.

         The project proposes a series of courses for Arizona  registered  nurses.
         Training involves four levels of instruction; basic, advanced,  refresher,
         and leadership. The four courses, ranging from three days to  four  weeks,
         will entail 11 sessions (23 weeks) for 420 enrollees.  For purposes of
         sharing coronary care facilities for instruction and clinical  experience,
         four other Phoenix hospitals will participate.  Cooperating  hospitals
         are: St. Joseph's Hospital and Medical Center, John C. Lincoln Hospital,
         Southside Hospital, Baptist Hospital and St. Luke's Hospital.

         In conjunction with the companion project #12, eight seminars are  to  be
         conducted in different localities.  Jointly, the projects will also
         provide consultation to Arizona Hospitals.

         A Liaison and Coordinating Committee for the overall Coronary Care
         Program in Arizona is to provide guidance in scheduling  and  evaluation.
         A project Advisory Committee will also be utilized in the evaluation
         process as well as the professional assistance of the University
         Department of Systems Engineering, a subcontract arrangement.

         Approximately 50% of the budget is for personnel, three full-time
         positions (Nurse Director, R.N. Instructor and Secretary) and  ten  part-
         time (Project Director, Medical Director, M.D. Instructor,  lecturers,
         four hospital nurse preceptors, Leadership Instructor and Physical
         Therapist).  Support is also requested for an electronics engineer,
         equipment, supplies, travel, subcontracted evaluation-service,
         publications and per them stipends for course enrol-lees.

         Second Year: $77,405                Third Year: $ 79,988

         Project #12 - @oronary Care Trainin@ Pro4ram of Arizona,
         Post-graduate Courses and Seminars for Physicians,               First Year
         Hospital Administrative Personnel and Trustees.                   $74,812

         Submitted by the Department of Cardiology, College of Medicine, University
         of Arizona, this is a companion to project #11, "Continuing  Education
         Program for Nurses."  This is a three-year proposal to provide three
         annual five-day courses for physicians from hospitals where  nurses  have
         attended or are scheduled to attend recognized training programs.
         Alternating between Tucson and Phoenix, the training will be conducted  in
         the coronary care units of five participating hospitals:  Veterans
         Administration, Tucson; University of Arizona Medical Center,  Tucson;
         St. Joseph's, Phoenix; St. Luke's, Phoenix; and Tucson Medical Center.
         It is anticipated that 108 physicians will be trained during the
         tliree-year project period.  Courses will be conducted simultaneously
         with the "basic" nurse course offered by companion project #11.  @




         ARIZONA Regional Medical           -4-                 RM00055 7/70.1
           Program


         In addition, eight annual one-day seminars will be conducted in eight
         localities and consultation services will be offered.
         Coordination with other projects of the "Coronary Care Training Program
         of Arizona", is to be accomplished through a Liaison and Coordinating
         Committee.  This Committee and the Regional Core Staff, assisted by
         The Arizona Department of Systems Engineering, will be responsible for
         assessing program effectiveness.
         Approximately 40% of the budget is for personnel, 2 full-time positions
         (secretary and assistant to the project director) and four part-time
         positions (the project director, two physician instructors, and a
         practicing cardiologist instructor).  Support is requested in all budget
         categories; the most significant amounts are for special consultant
         services to hospitals, three consultants for each of the eight seminars,
         evaluation subcontract and travel.
         Second Year: $68,648                    Third Year: $70,640





       ARIZONA Regional Medical              -5-                  RM00055 7/70.1
         Program



                               REVIEW  AND  FUNDING  HISTORY

       Ist Year  Planning  Award          4/l/67  -  3/31/68             $119,045
             (February 1967 Council)

       2nd Year  Planning  Award          4/l/68  -  3/31/69             346,125
             02 Supplement                I/l/69  -  3/31/69               62,983
             (May 1968  Council)
       Chronic Pulmonary Disease Program  -  Application  for  "Earmarked  Funds"
             (May 1968  Council)                                         Deferred
             (Site Visit August 1968)
             (November 1968 Council)                                     Disapproval with
                                                                         Advice  to  Resubmit
       03 Year Planning Award             4/l/69  -  6/30/69             138,015
       03 Year Extended with Funds        4/l/69  -  9/30/69             255,303
       03 Year Extended with Funds        4/l/69 - 12/31/69              361,933

       INITIAL OPERATIONAL APPLICATION
             (May 1969  Council)
             (Site Visit May 1969)
             (August 1969 Council)
                                                  Fun0e@    A-pproved Future Level
        rojects (1/l/70 - 12/31/73)               01  Year     02   Year     03  Year
   'W@00     -Core Staff Activities               $503,300      $@03,300        0
         I -  Checklist - 20th Century
              Books (Approval in Principle)         0             0             0
         2 -  Medical Library Network              35,211         35,211       35,211
         3 -  Chronic Pulmonary Disease           150,000        112,000      120,000
         4 -  Continuing Education in
              Nursing Care of Patients             56,895         74,307       84,118
         5 -  Recruitment and Cont. Ed.
              Social Service                       50,000         50,000        0
         6 -  CPR (revised March 1970)            Approved   not funded as of 4/9/70
                                                  $795,406      $774,818     $239,329
       FIRST  OPERATT'@ONAL SUPPLEMENT  APPLICATION

             (August 1969 Council)
         7 -  Continuing  Education,  Coronary  Care   Disapproval with  advice  to  resubmit
       i@ 8 - Continuing Education Program for
              Nurses                                   Disapproval with  advice  to  resubmit
         9 - Long-Term  Continuing  Ed.  for  Nurses   Disapproval with  advice  to  resubmit






                                                                 RM00055 7/70.1
         ARIZONA Regional Medical            -6-
           Program


         SECOND OPERATIONAL $UPPLENENT APPLICATIONAL

              (March i970 Council)
         #10 - Nutritional Care Program        Disapproval wit@ advice to resubmit
        *August 1969 Council - Deferred for further study
         December 1969   Adopted CPR policy
         March 24, 1969 Region submitted a revision in keeping with policy



































                                                                            5/5/70








                                                              A Privileged  Communication


                            SUMMARY OF REVIEW AND CONCLUSION OF
                                 JUNE 1970 REVIEW CO@IITTEE


                              ARIZONA REGIONAL @IEDICAL PROGRAM
                                      RM 00055@- 7/70.1


                      FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL



              General:  The Review Committee concluded that this application for
                        $448,076 (d.c.o.) for three years should be funded in  the  re
              duced amount of $426,326 with conditions and an expression  of  concerns
              as indicated below under specific projects.

              It was noted that this application is the outcome of the  disapproval  of
              three continuing education training projects reviewed in August  1969  and
              Council's suggestions. The Region is redeveloping a  program  for  coronary
              care training which will involve five projects, two of which are  in  this
              application. The remaining three are still in the  development  9tage  and
              will be submitted later. Reasons for disapproval of  the  previous  proj-
              ects were taken into account in the preparation of this application.
              Interlocking relationships between the two projects is noted as  well  as
              cooperative arrangements in the Tucson and Phoenix  areas.  Funding  will
              allow the ARMP to begin a regionalized coronary care program.


              Project #11   Coronary Care Training Pro,-,ram of Arizona, Continuing
                            Education for Nurses

              Critiaue: The Committee noted the favorable review  comments  prepared  by
                         the Continuing Education and Training  Branch  staff.  However,
              the Committee believed the project leadership may not be as strong  as  is
              implied in the application. Also, there was concern  that  the  curriculum
              is too didactic and should be more clinically oriented.  Committee
              questioned why "training in nursing administration" is a  prerequisite  for
              the associate project director position. It was also  believed  that  send-
              ing hospitals should share half the costs for stipends.

              Recommendation: Approval I with the condition that only  half  the  costs
                               of stipends be supported with RMP funds,  the  remainder
              being the responsibility of the participating hospitals.  It is also
              recommended that the ARMP be informed and requested to respond  about  the
              concerns, as well as the question about the  administrative  requirement
              for the associate project director.


              Project #12 - Coroiaarv Care Training Program of Arizona,  Post-graduate
                            Courses and Seminars for Physicians, Hospital Administrative
                            Personnel and Trustees










              Arizona                              2



              Critique: Committee concurs  with  the  review  comments  by  the  Continuing
                          Education and Training Panel.  'In general, the plan seems well
              designed and the  need  is  adequately  founded.  The  operational  objectives
              are clear, but the goals relative to change  of  behavior  are  not  and  are
              less measurable.  In terms of time frame, staffing and utilization of
              resources, the project is feasible.  The  foci  of  the  evaluation  are  upon
              the acquisition of knowledge and the degree to which the project will
              stimulate the development of additional care facilities.  There should
              be a greater focus on the outcome of  training  as  it  will  effect  patient
              care. Of major concern is  the  method  of  selecting  physicians  for  train-
              ing.  It is hoped that physicians accepted for the course would come from
              hospitals with specialized facilities  and  equipment,  and  that  they  would
              be utilized with greater precision after training.

              Recommendation: Approval I in  the  amount  requested.  It  is  a  so  recom-
                                mended that the ARNP be informed of the concern about
                                the selection of physicians.



                                  S      Y OF RECOMHENDATIONS
                                          Direct Costs


              Projects                01        -02                   03           Total

              #11 Cont'g           $ 69,333       $ 70,155        $ 72,738         $212,226
              Ed.  for  Nurses


              #12   Post-grad.       74,812         68,648           70,640         214,100
              Courses  &  Sem.
              for Phys. Hosp.
              Adm.   Personnel
              & Trustees

                 TOTAL             $144,145       $138,803        $143,378         $426,326















                                                                    DRMP  7/2/70



















             0                                                                                                                            0






                             REGIONAL NEDICAL PROGRAMS SERVICE
                  SUMMARY OF AN OPERATIONAL SUPPLENENT GRANT APPLICATION
                                 (A  Privileged  Communication)


           ARKANSAS  REGIONAL  MEDICAL  PROGRAM               RM 00052 7/70.1
           University of Arkansas Medical Center              June 1970 Review Committee
           500 University Tower Building
           12th at University
           Little Rbck, Arkansas  72204


           PROGRAM COORDINATOR:  Charles W. Silverblatt, M. D.


           Requested
           Program
           Period             lst Year        2nd Year        3rd Year       Total

           Direct Costs       $88,149         $82,769         $83,896        $254,814
           Indirect Costs      13,771          14,459          15,905          44,135


           TOTALS            $101,920         $97,228         $99,801        $298,949

           HISTORY: Arkansas received its  first  planning  grant  ($341,846  d.c.6.)
                      on April 1, 1967 and its second, for   the same amount, on
           April 1, 1

           A site visit was conducted in September, 1968 to examine the Region's
           readiness for operational status. The  site  team  had  some  reservations
           about the lack of a continuing education component on the core staff
           and the rather weak financial condition of the medical school, but on
           the whole, they were impressed with the community involvement, the
           active participation of the Regional Advisory  Group,  and  the  directions
           planned by the director and core  staff.  Following  Council  approval  in
           November 1968, an 01 operational award ($687,506  d.c.o.)  was  issued  on
           February 2, 1969, including support for core and ten projects.

           A second site visit was made in July 1969 for the twofold purpose of
           reviewing Arkansas's progress in developing  its  program  and  evaluating
           ten supplemental project proposals.  The site team concluded that
           considerable progress had been made since  the  earlier  visit,  especially
           when consideration was given to the limited resources  the  Region  had  to
           work with. The only area of concern  was  the  Regional  Advisory  Group's
           project rather than planning orientation.

           On February 1, 1970, the Region was awarded an  02  continuation  award  of
           $801,306 ($687,506 commitment plus  $113,800  carryover)  supporting  core
           and 13 projects.  See the History Supplement following this summary sheet
           for a listing of projects.






           ARKANSAS REGIONAL 'MEDICAL PROGRAM      -2-            RM 00052 7/70.1


           As a result of the recent release to RMPS of funds  that  had  been
           placed in administrative reserve by the Bureau  of  the  Budget,
           negotiations are now under way to fund five of the Region's back-
           log of approved-.unfunded projects in the amount  of  approximately
           $200,000.

           Also of note is the appointment  in  January  1970 of Charles  W.
           Silverblatt, M.D.,  as  Program  Coordinator.  Dr. Silverblatt
           succeeds Dr. Roger Bost.

           PRESENT APPLICATION: This application requests    supplemental support
                                 for one new project,  #35  -
           for Dieticians and Health  Facility  Food  Service Supervisors   n
           Arkansas.  Direct costs only are noted below.
           Project #35 - Continuing Education  for  Dieticians  and  Health  Requested
                          Facility Food Service  Supervisors  in  Arkansas.  First Year
           The goals of this proposal are to improve the  skills  of  the     $88,149
           personnel (dieticians, dietary  consultants,  and  food  service
           supervisors) in charge of  nutritional  services  in  hospitals,
           nursing homes, and related facilities and  to  encourage  pre-
           sently inactive dietetic personnel to return  to  work.  Of  the
           331 hospitals and nursing homes in Arkansas, only  71  have  any
           supervision of food service by qualified  dieticians  (of  which
           there are 59 working full and part-time).  Because  of  the  lack
           of qualified dieticians, greater  responsibility  for  dietary
           services has fallen to the food service supervisors and to
           relatively untrained persons acting in this capacity.  A survey
           of the 331 institutions showed that the @      could expect
           520 participants per year at  dietetic  courses.  There  are  32
           inactive dieticians in the State, 18 of  whom  indicated  through
           a survey their interest in returning  to  active  employment  if
           training opportunities and  jobs  were  available.
           Since the types of training will differ with the sophistication
           of the audience, several presentations are planned.  These
           programs and public forums will be held in four different areas
           of the State as follows:

                 1. Seminars for dieticians and  food  service  supervisors
           of two and one-half days length in  Little  Rock,  Fayetteville,
           Jonesboro, and Arkadelphia are expected to accomodate 400
           participants.
                 2. A two-week diet therapy  short  course  for  dieticians
           will be presented at the University of  Arkansas  Medical  Center
           in  Little Rock for 25 people.








          ARKANSAS REGTONAL MEDICAL PROGRAM     -3-         RM 00052 '7/70.1



               3.  Institutes for diet consultants in Little Rock and
          Fayetteville will be presented for an expected 70  participants.
          Each course will be two and one-half days in length.

               4. One-day workshops for food service supervisors  in  each
          of the four locations mentioned above will train a total of  200
          people.

               5.  Hour-long public forums will be presented in each of the
          four areas.


          Thirteen organizations and institutions in Arkansas have pledged
          to participate in and to support this program and plans have
          been made to coordinate this project with other @    on-going
          activities. An evaluation protocol is presented  which  includes
          measuring the upgrading of skills of those participating through
          pre and post tests and determining the number of inactive personnel
          who return to the field as a result of this program.  After  the
          three-year period of the program has been completed, educational
          institutions within the State will be encouraged to offer continuing
          education programs for dieticians and food service personnel.  The
          first year request for $B8,149 includes $31,866 for personnel and
          consultants and $24,900 per them for course participants.

          Second Year:  $82,769                 Third Year:  $83,896








                      ARKANSAS REGIONAL MEDICAL PROGRAM         -4-                  RM 00052 7/70.1


                                                          HISTORY SUPPLEMENT



                                                                                       Annual               Initiation
                      Project                  Title                                 Support d.c.o.            Date
                          1             Core Support                                 $304,425                  4-67

                          2             Coronary Care and Supporting
                                        Diagnostic unit for Postgraduate
                                        Training of Physicians and Nurses              82,295                  2-69
                          3             Nurses Coronary Care Training                  51,526                  2-69

                          4             Pilot Study  -  Computerized  Assistance
                                        to Cardiac Patient Care                      Unfunded

                          5             Cardiopulmonary  Resuscitation   Program       29,533                  2-69
                          6             Computerized Tumor Registry                    57,428                  2-69
                          7             N.W. Arkansas  Regional  Cancer  Program       23,020                  2-69

                          8             Health Careers Recruitment                     26,065                  2-69
                          9             Regional Hospital Medical Library System       31,037                  2-69

                        10              Nuclear Medicine Technology Training
                                        Program                                        18,902                  2-69

                        11              Dietetic Internship and CE Program           Disapproved

                        12              Western Arkansas Cancer Study                  24,705                  2-69

                        13              CE for Nursing  Personnel  and  Citizens       38,570                  2-69

                        14-19           Revised as Project #'a 28-33

                        20              North Central Arkansas Region Cancer
                                        Center                                       Approved/Unfunded

                        21              Twin Lakes Rehabilitation Center             Approved/Unfunded

                        22              North Central Arkansas Stroke
                                        Rehabilitation Center                        Approved/Unfunded

                        23              Revised as Project #34

                        24              Remote Computerkssistance to
                                        Arkansas Pbysicians

                        25              CE for Physicians
                        26              CE for Pharmacists                           Approved/Unfunded

                        27              Refresher Training  for Medical
                                        Technologists and Technicians                Approved/Unfunded
                        28              CE in Cardiology for Physicians              Approved/Unfunded

                        29              Model Cardiac Care Unit - Stuttgart
                                        Memorial Hospital

                        30              Area-Wide Intensive Care Unit and
                                        CF in Coronary Care for Physicians
                                        and Nurses









                       A@%'@SAS REGIONKL @U-@DICAI, PROGWI               -5-            IZ@l 00052 7/70.1



                          31              Instruction in Neurologic Aspects
                                          of Stroke, Brain Tumor and Cancer             Approved/Unfundc@d

                          32              Demonstrqtion and Training in Care
                                          and Handling of Stroke Patients

                          33              CE in X-ray Technology and Relited
                                          Fields                                        Approved/Uiifutided

                          34              Regional Laboratorv Quality Control           Approved/Uiifunded








                       *An award of $200,000 is expected to be made before July 1, 1970 for partial
                        support of these five projects,
















































                                                                                  DRMP/GRB
                                                                                  5/28/70





                                                                  !eRed Communication
                                                          A Privi,

                                SMILRY OF REVIEW AND   CONCLUSION  OF
                                     JUNE 1970 REVIEW  COMMITTEE
                                 ARKANSAS REGIONAL MEDICAL PROGRAM
                                           RM 00052  7/70.1
                           FOR CONSIDERATION BY JULY 1970 ADVISORY     COUNCIL
                                                                             ogram has
               General:  It was noted that the Arkansas .Regional  Medical  Pr s of the
                         limited resources but an expansive  program  in  term
               number and types of activities being supported.  the reviewers were
               impressed with the breadth of the program.
               ,Project #35 - Con         ucation            iails and Healt  Facility
                            Foo  Service  SuDervisor  in Arkansas.
                         The Committee agreed with the Continuing Education and
               Critique: Training Branch that the project proposal presents a well-
               documented needt a technically--,@ound methodology, and a good phaseout
               plan for the continuing education of dieticians and food service super-
               visors.  Since food service supervisors, by definition, are concerned
               partly with management functions, some time was devoted to a discussion
                                                           ibil4ty for continuing
               of the personnel level at which MT respons       I
               education ends.  Although the reviewers agreed that their reactions
                5,_I-it be different if this were another geographic area where nursing
               mi@                                                            at the
               homes might have dietition staff, a consensus was reached th
               quality of food service supervisors has a direct bearing on the quality
                                                                             h-
                                            ursing homes in Arkansas, and t is is a
               of health care rendered by n
               legitimate area for RllP support.
               Even though the general impression of this project was most favorable
               the Committee had certain specific concerns it wanted to build into its
               recommendation of approval-
                    1.   The project advisory committee is composed of dieticians only.
                         The reviewers believed the addition to the committee of one or
                         two food service supervisors would be most helpful in assuring
                         that the continuing education program is designed to -meet the
                         needs of this group.
                    2.   The proposal does not address the beneficial effect this project
                         could have as a stimulus for encouraging the involvement of
                         Arkansas community colleges, high schools, and other educational
                         resources.  For instance, community colleges might be induced to
                         develop associate degree programs in dietetics.
                     3.  The Committee would like to see a careful evaluation of the
                         PrOL,,ram's progress and effectiveness after two years of
                         operation.




            ARKAliSAS Regional Medical Program                    RM 00052


                 4.  The Committee recommended, as it did with other continuing
                     education projects reviewed during this cycle, that a 50%
                     cost-sharing principle be applied to the amounts budgeted
                     for per them and travel,_,,for course participants.
            Recommendation:  Approval I in a reduced amount for two years with the
                           .  specific conditions noted above: expansion of the
            advisory committee to include food service supervisor representation;
            involvement of educational resources in Arkansas; comprehensive progress
            report and evaluation of two years' experience; and reduction of the
            budget to provide for 50% cost-sliaring of participants' per them and
            travel expenses.

            01   $71,330                             02   $65,950

































                                                       DRMP/CRB
                                                       7/10/70




















                                                                           0






                                 REGIONAL  MEDICAL  PROGRAMS  SERVICE
                    SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                   (A Privileged Communication)
           BI-STATE REGIONAL MEDICAL PROGRAM                        RM 00056  7/70.1
           (Washington University)                                  June 1970 Review Committee
           607 North Grand Boulevard
           St. Louis, Missouri  63103
           Program Coordinator:  William Stoneman III, M.D.
           Requested           Ist  Year          2nd  Year         3rd Yea-,           L
           Direct Costs         $146@815           $123,165         $128,790       $398,770
           Indirect Costs         52,325             55)184           58,200         i65,709

           TOTAL                $199,140           $178,349         $186,990       $564,479
           History:  The Region was awarded an initial planning grant for the year
                    April 1, 1967 through March 31, 1968.  The original award was
           extended for a seven-month period  through  October  1968.
           Staff review of the continuation application for Core planning resulted in
           a second-year award (November 1, 1968 through October 51, 1969) of $644,922
           (total costs) which included basic funding of $331,622 and a carryover of
           $313,300 from the first-year planning grant.
           The Region submitted its first operational application during December 1968.
           This application requested support for additional Core staff to initiate the
           operational program, plus funds (2% overhead) to be used for    'developing
           satisfactory financial arrangements with affiliated institutions and for
           insuring the accurate accountability of funds.  The overhead requested was
           subsequently denied because of a  lack  of  justification.  The  original
           operational application requested support for six projects.
           A preoperational site visit was conducted during April 1969.  The team's
           report favored having the  Region  become  operational.  Following  this,
           May 1969 Council recommended approval of three of the six projects (see
           last page for History Supplement - Projects #2, #4, and #5) plus the
           additional Core support requested.  It was recommended that the three remain-
           ing projects be returned for revision.  Effective July 1, 1969, an award of
           $433,395 (total costs) was made to the Region - to support the Core Supplement
           plus the three approved projects.
           During the July/August 1969 review cycle, the Region submitted a supplemental
           operational application which contained a renewal request for Core support,
           plus support for three operational projects.  Council recommended approval for
           the Core renewal and the three projects.  Due  to  fund  limitations,  the  three
           projects are classified as "approved - unfunded" projects (see History Supple-
           ment - Projects #7, #8, and #9).  The Core renewal has been awarded.
           The Regional Advisory Group is composed of 56  members,  representing  a  mix  of
           physicians, allied health personnel, personnel from health organizations, and
           public members.  Reorganization of the RAG has been planned for some time.  The





         DI-STAT,,E RECIONAL MEDICAL PROGRAM             -2                 RM 00056  7/70.1

         present--@xperienced group has been retained because of substantial
         tinr-erLa'Lnties regarding major strategy decisions at this level.  Of
         ma or concern are the uncertain prospects for funding and the possible
         necessity for organizational changes involving priorities.  Also, in
         .the near future, the Regional Advisory Committee and the Administrative
         Liaison-Co=ittee plan to recommend a reorganization of the Core staff
         so the Southern Illinois University (one of the three participants in
         the   ini tial consortium agreement) will be included in Core activities.
         A Dean has recently been appointed to the new Southern Illinois University
         School of Medicine.  There will now be three medical schools in t e Region.

         The advent of Regional Medical Programs has acted as a catalyst and
         provided the means by which St. Louis University and Washington University
         have   lea'rned to cooperate in solving the multitude of health problems
         existing in the Bi-State area.  It can be assumed that this feeling will
         be communicated to the new medical school.

         Present  Application:  This  is  a  request  for  two  individual  projects   which
                                 represent the Region's initial attack on heart disease.
         (Note:   During the April/May 1969  review  cycle,  a  proposal  -  Project  i@l  -
         for   the               of  a  program  of  rehabilitation  and  a  secondary  pre-
         vention  Eo-- -;ati--r-ts who have had myocardial infarction, was considered.
         In -rec;.,r,-!,-'nending "non-approval - revision requested," Committee viewed  the
         program described as a clinical research activity which might be more
         acceptable if oriented toward the development of a service.)

         Direct costs only are noted in the following project descriptions.
                  7
                                                                                  Requested
         Project #12 - A  Proposal  to  Establish  a  Coronary  Care  Trainin?,   First Year
                        Program  for  Nurses  -  St.  Louis  University  School      $73,015
                        of  Nursing  and  Allied  Health  Professions.  This   is
         a three-year  request for coronary care training for  nurses,  to
         meet the Region's need  for  nurses  trained  in  care  of  the  acutely
         ill coronary patient.

         A survey recently conducted by the Bi-State RMP Heart Committee
         revealed that  the  rate  of  establishment  of  coronary  care  units
         outpaces  the supply of trained personnel needed to man the units.
         The surv6  was the outgrowth of the activities of the RMP Heart
                   y
         Committee.  The  Heart  Committee's  deliberations  led   to   formation
         of a subcommittee  on  coronary  care  training;  the  findings  of  the
         subcommittee motivated this proposal.

         Question naires were sent to 154 geographically well-distributed
         hospitals,  and  78  interested  hospitals  responded.   The   hospitals
         care  for  a  substantial  portion  of  the  Region's  myocardial  infarc-
         tions.

         The program  will  consist  of  eight  five-week  courses  per  calendar
         year. A minimum  of  210  nurses  will  be  trained  during  the  three-
         year  period.  The  courses  will  include  both  didactic  and   clinical
         instruction and are  designed  to  meet  the  needs  of  nurses  who  are,




             BI-STATE REGIONAL MEDICAL PROGRAM           -3-                  RM 00056 7/70.1

             or will be, working in a coronary care  unit.  The  courses  will  be
             open to registered nurses nominated by a  hospital  with  a  coronary
             care unit currently in operation, or by  a  hospital  planning  to
             install such a unit. On return to  their  own  hospitals,  the  nurses
             are expected to pass on their newly acquired knowledge and experience.

             Cooperating in the instruction portion of  the  program  will  be:
             St. Louis and Washington University Schools of Medicine, Barnes
             Hospital, St. Mary's Hospital, John Cochran Veterans' Administration
             Hospital, and  the St. Louis Heart Association.

             Second Year:   $59,025                        Third  Year:  $61,623

                                                                                    Requested
             Project #13 -  A Proposal to Establish a  Program  of  Rehabilitation  First Year
                            for Patients Who Have Had a  Myocardial  Infarction  -   $73,800
                            Washington University School of Medicine.  The purpose
             of this proposal is:  1) to provide patients (in the St. Louis area)
             who have had a myocardial  infarction,  with  rehabilitation  services
             which will help them return to an active, productive  life;  2)  to
             educate members of medical and lay communities regarding the benefits
             patients can derive from coronary rehabilitation procedures.

             This project is an outgrowth of a recent survey  conducted  by  the
             Bi-State RMP Heart Committee. The survey showed  that  84%  of  the
             responding physicians had indicated that  they  would  be  interested
             in such a program, and stated that about  580  patients  would  be
             referred by them to a coronary rehabilitation program over a twelve-
             month period.

             Headquarters of the program will be in the Department of Preventive
             Medicine, Washington University School of Medicine and will have two
             operational bases, the Irene Walter Johnson Rehabilitation Institute,
             and the St. Louis Heart Association.  The program will also use the
             facilities of the Jewish Association of  Community  Centers  and  the
             downtown YMCA.


             The program will consist of the  following  four  phases:  1)  initial
             patient evaluation; 2) diet therapy; 3) exercise therapy; and 4) follow-
             up therapy.


             The program will be available to any patient in  the  St.  Louis  area
             who has had myocardial infarction and  who  has  written  referral
             from his physician for inclusion in the program.

             Education of the medical profession and the  lay  community  will  be
             accomplished through lectures and demonstrations and will be arranged
             and presented under the auspices of the St. Louis Heart Association.

             Evaluation in terms of the stated objectives will be as follows:  To
             determine whether the rehabilitation service has helped the patient
             return to an active productive life, patients will be interviewed by





          BI-STATE REGIONAL MEDICAL PROGRAM            -4-              PM 00056 7/70.1
          the program's social workers at six-month intervals.  The success
          in educating the medical Community will be evaluated by:  1) keeping
          a, record of the rate of patient referrals by physicians to the
          program; 2) keeping a record of the number of physicians referring
          patients to the program; and 3) at twelve-month intervals physician
          opinion will be sampled on the value of coronary rehabilitation.
          Second Year:  $64,140                        Third Year:  $67,167































                                                               DRMP/GRB
                                                               5/21/70







            BI-SI'ATE Regional Medical. Program                                RM 00056 7/70.1

                                           HISTORY SUPPLEMENT


            LISTING OF CURRENT STATUS OF CORE AND OPERATIONAL PROJECTS IN BI-STATE


              A - FUNDED PROJECTS

            Project                                                       Amount Supported (D.C.)
            Number    Title                                               Through 10/31/70

            00        Planning - Core support                                    $559,487
                      (Includes $11,950 carryover funds)

              2       Cooperative Regional Radiation Therapy
                      Development & Support Program                               152,071

              4       A Comprehensive Diagnostic Demonstration Unit
                      for Stroke                                                  92$243

              5       A Nursing Demonstration Unit  in  Early  Intensive
                      Care of Acute Stroke                                        80$077


              8       To Establish a Cooperative  Regiona  In  ormat  on
                      System for Health Professionals                             38,500
                      (Note: This project was  approved  for  a  three-year
                      period by August 1969  Council.  The  Division  is
                      currently in the process of awarding $38,500 for
                      the first year.)

                                                         TOTAL                   $922,378

              B   APPROVED UNFUNDED PROJECTS

              7       To Establish a Major  Radiation  Therapy  Facility
                      (Regional implementation is planned for 10/l/71.)

              9       To Inaugurate a Program for Health Surveillance,
                      Health Education, and  Health  Care  Accessibility
                      for Residents of a Low-rent,  Urban  Housing  Project
                      (Scheduled for funding effective 7/l/70.)

              C    PROJECTS NOT APPROVED

              I       A Program of Rehabilitation  and  Secondary  Prevention  with
                      Myocardial Infarction
              3       Regional Consultative & Educ;itional Programs in Cancer Chemotherapy

              6       Center for Continuing Education in Long-term Care
            10        A Proposal to Inaugurate an Operating Room Technician
                      Training Program
            II        A Proposal to Establish a Center for Continuing Education in
                      Long-term Cate (Note:  This was the revised version of llroject #6.)

                                                                                   DRMII





                                                               (A Privileged  Communication)


                                 SUMMRY OF REVIEW AND CONCLUSION OF
                                 JUNE 1970 REVIEW COMMITTEE


                                 BI-STATE REGIONAL MEDICAL PROGRAM
                                         RM 00056 7/70.1


                      FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL

           General:  The Review Committee recommended that this Supplemental Operational
                     Application, containing two individual  projects  and  requesting
           $398,770 d.c.o. for a three-year program period, be  partially  funded  at
           $178,677 d.c.o., to support Project #12 for the time requested (thr6e years),
           for a reduced amount. Committee believed that action  on  Project  #13  should
           be "nonapproval" - no RMPS funding recommended.

           Project #12 - A Proposal to Establish a Coronary Ca-re Train@@@ro        for
                         Nurses - St. Louis University School of  Nursing  and  Allied
           Health Professions.

                      The reviewers believed.that the preplanning of  this  program  had
                      been accomplished through a survey generated  as  an  outgrowth
           of the activities of the Region's Heart Committee.  The  Heart  Committee  has
           established a subcommittee on coronary care training; the  findings  of  this
           subcommittee motivated this proposal.

           Committee members were influenced somewhat by the excellent  review  of  this
           proposal conducted by the Ad Hoc Cardiovascular  Study  Panel.  The  resources
           and procedures described appear to be adequate to meet  the  primary  objectives.
           A question was raised regarding the practicality of the number of courses
           proposed (eiobt five-week courses). It was noted  that  the  applicant  requested
           neither stipends nor per them support but the request for'travbl appeared
           excessive.  It was believed that a better method is needed for the selection
           of candidates for the training courses. The need  and  justification  of  a
           two-bed, fully-equipped mockup unit was questioned.  The  Panel  members  felt
           strongly that all clinical equipment must be capable of actual patient
           monitoring and the Committee agreed.

           In recommending approval in time and for a reduced  amount,  the  Committee
           further recommended that conditions of approval  should'be:  1)  that  the
           applicant establish a method to better determine the needs of the individual
           candidates and examine closely their educational  qualifications;  2)  reduce
           the amount requested for equipment by deleting one mo6kup  unit  and  reducing
           by 5(f/. the remainder of the equipment request; 3) reduce travel  expense
           by 5Crk; 4) improve the method of evaluation; and 5) the Applicant  should  be
           encouraged to restrict.both the number- of courses offered and the  number  of
           nurses enrolled per course.

           Recommendation: Approval in time and reduced amount  subject  to  the  conditions
                             outlined above.


           Direct Co    Onl       ist Yr.      2nd Yr.       3rd Yr.
                                  $59,229      $58,425       $61,023





           BI-STATE Regional Medical Program                                     RM  00056

           Proj,ect #13 - A Proposal to Establish a Program of Rehabilitation for Patients
                         Who Have Had a  Myocardial  Infarction  -  Washington  University
           School of Medicine.

           Critique:  Members of the.Review Committee noted that during.-the April/May 1969
                      review cycle, a similar proposal (for the Establishment of a Program
           of Rehabilitation and Secondary Prevention for Patients Who Had           rdial
           Infarction) was considered,  In recommending "nonapproval - revision requested
           for the former proposal, the reviewers considered the program as a clinical
           research activity  which  mig,ht be more acceptable if oriented toward the
           development of a service.

           In considering this revision the reviewers noted that the applicant had
           apparently developed a sufficient need through a survey of physicians.,
           The objectives are clearly stated as to numbers, examinations, and programs
           to be undertaken.

           There was some concern expressed in this review (as in the review by the
           Ad Hoc Cardiovascular Study Panel) as to whether the project can be accomplished
           in the three-year program period proposed.

           The Committee believed, however, that this   is a tenuous proposal for the
           following reasons:

             1) Although a survey of physicians has been accomplished, the pr    ogram lacks
                the endorsement of the Medical Society.

             2) Lack of involvement of rehabilitation personnel in the planning of this
                proposal.

             3) Method of early evaluation is unrealistic.

             4) No concrete plans were presented for phasing out this activity.

             5) The overriding concern was that the rehabilitation of the heart patient
                is the direct responsibility of the  patient's  physician  and,  as  such,
           it was doubted that referrals for this type  of  service  would  actually  take
           place in the numbers anticipated.  In view of these overriding concerns, the
           Committee did not believe support is warranted.

           Recommendation:  Nonapproval    no RMPS funds recommended.













                                                                               7/i/70






               BI-STNRE Regional @tedical Program               -3-                 RM 00056


                                            SUM@TARY OF RECOT@,NDATIONS


               @O @C t-
               Number               Title                          Ist Year      2nd Year       3rd Year

                 12         A   Proposal- to Establish
                            A    Coronary Care Training           $59,229        $58,425      $61,023

                 13              o o.,3 -to Escablisl, A
                                 rani  of Rehabilitation
                            for  Patients Who Piave Had          Non--approval -
                                 o@a dial Infarctiol             No @IPS funds recommended

                                                    TOTALS      $59,229         $58,425      $61,023



               Year                                 TOTAL DIRECT COST

               01)                                        $59,229
               02)                                        58,1-.25
               03)                                         61,023
                                           TOTALS        @179,677























                                                                      DP,21P GRB
                                                                      7/6/70



                                                                                                                                                  m















                                                                           0                                                              0





                                REGIONAL MEDICAL PROGRAMS SERVICE
                       St@R'@ OF AN Ol.'PRATIONAI, SUPPLEMENT GRANq' APPLICATION
                                     (A Privileged Conununicati.on)

         (,'Al,,] l@'C)R,141A MEDICAL EDUCATION AND                    RM 00019  7/70.1
          RESFARCII FOUNDATION                                         June 1970 Review Committee
         69'3 Skitter Street
         San Francisco, California  94102


         I)rop.ram Coordinator:  Mr. Paul D. Ward

         R,.e@ested
         @IT-ogram
         Peri(-.,d:        lst  Year           2nd  Year              3rd  Year       Total
         I)i.rect Costs    $535,250            $505,893                $549,323     $1,590,466
         Indirect Costs       68,880              87,502                 93,683        250,0 5


         ,j,o,rAi,         $604,130            $593,395                $643,006     $1,840,531
         .1,11STORY: The initial planning grant was awarded to  the  California Region
                   in November 1966.  A  second-year  planning  grant  provided
         @3upport for the eight Area components of the Region, the California
         Medical Education and Research Foundation (fiscal agent), and central
         Core staff activities. The request  for  the  second-year  planning  grant
         proposed the establishment of a new Area IX to be based at the Charles R.
         Drew Post-Gradtiate Medical School in Watts-Willowbrook.  The recommendation
         of approval provided for designation of Area IX when  the  CRMP  feels  it
         is indicated. The Region'.-  first  operational  award,  totaling  $2,232,864
         was effective July 1, 1968. An  operational  supplement,  in  the  amount  of
         @140,124, was awarded September 1, 1968,  to  support  the  six  communities
         project of the Northeast San  Fernando  Valley  area.  Two  extensions  were
         made of the planning grant to permit merger of  the  planning  grant  into
         the operational grant and for Committee and  Council  to  assess  a  request
         for an increase in  the  Core  support.
         2'@ spc!cially-structured site visit team visited each of the  Area  offices
         in the Region from April 14-18, 1969 to:  (1) relate individual Core
         requests to ongoing operational projects,     2) analyze  the  organizational
         and functional structure of each area and its relationship to the central.
         office and (3) recommend future action. As  a  result  of  the  site  team's
         recommendation, an expanded Core was  approved  by  May  1969  Council.  The
         current annual level of support (in the  second  year)  is  $6,390,227  which
         provides support for the eight  (nine  including  Watts-Willowbrook)  Area
         (,t-)iiiponeTiLs, the California Medical Educati.on and Research Foundation
         (CMER.F--fiscal- agent), and central Core staff  activities.  The  California
         i   is presently funded under a single operational grant, effective
         ,J@,ily 1, 1969 in the direct cost amount of $7,806,671 for a 14-month period.
         This amount supports 17  ongoing  operational  projects,,  Nineteen  Council-
         approved projects are as yet not implemented.





             CALIFORNIA Medical Education                   -2-                       RM 0001.9    7/70@l
                and Research Foundation



             A  site  visit  of  July  7-9-,  1969  in  Los  Angeles,  recommended  approval  of   eleven
             new projects in the approximate amount of $1.5 million (D.C.), and this action
             was  concurred  in  by  both  Committee  (July  1969)  and   Council   (August   1969).   To
             complete  the  "backlog"  of   projects   awaiting   review,   a   10-project   supplement
             was  the  subject  of  a  site  visit  in  October  1969.   Five   projects   received
             affirmative  action  by  Council  in  December   1969,   amounting   to   $569,776   (D.C.)

             Presented  to.March  1970  Council  were  six  new   supplemental   projects   and   'one
             renewal  (Medical  TV  -  #7R).  The  renewal  was  approved   in   the   requested   amount
             for  one  additional  year  only.  Three  of  the  six   new   projects   were   approved.

             A supplemental award is currently under negotiation which will enable the
             region  Lo  activate  seven  new  pro@ects   from   its   backlog   of   Council-approved
             but unfunded projects.  The regidn is preparing a third year continuation
             request  for  submission  on  July  15,  at  which   time   re-budgeting   to   accommodate
             the remaining backlog of Council-approved but unfunded activities is expected.

             PRESENT  APPLICATION:  This  application  is   composed   of   two   new   operational
                                     .projects  and  a  revision  of   one   previously   submitted
             but returned with suggestions for specific revisions.  Both of the new
             projects were studied by a technical review panel in the region as part
             of the new review procedure adapted by CCRMP last year.  As a result of
             this  technical  review,  both  new  programs   were   revised   before   submission   to
             D@IP
                                                                                  First Year
             "roject #41 - Area I - Patient Monitoring                             $263,186

             BACKGROUND:  The  site   visit   team   which   reviewed   the   supplemental   application
                             from  this  region  in  October  1969  visited  @lt.  Zion  Hospital   in
             San  Francisco  where  this  project  is  based.  The  team   saw   a   demonstration   of
             t!ie  equipment  which  was  developed  by  the  Lockheed  Laboratories,   and   had   the
             opportunity  to  discuss  it  in  depth  with  the   technical   people   from   Lockheed
             and  also  the  Project  Director  and  his   staff.   The   monitoring   equipment   was
             described  by  the  proposers  as  an  "early   warning   system"   with   application
             to  patients  with  a  variety  of  diseases  and  not   necessarily   restricted   to
             lieart disease.

             Questions were raised by the site visitors concerning various technical
             I)roblems,  i.e.,  false  alarms,  the  decision-makinc.,  process  when   a   warning
             signal occurs, required training for nurses and other hospital personnel,
             ctc., iii orc;er to utilize the system, etc.

             'rile evc@luiti(iri i(ietliodology appeared to be in need  of  more  planning  and  tlic,
             recording system for the data was vi-ewed as deficient.

             The  si.tc,.  visitors  felt  generally  that  this  is  an  exciting  prospect,  but  i-
             iieed (@f more research and (leveloprii(,nt, particularly in @l clinical S(,tti.n,@,,  -:it
             the i@it. 7,ion Hospital.    It was not belicved to be  read),  for  field  tri.@'.ilv
             @jitlit)zit  further  clarification  of  the  validity  of  signals,  development  of   in
             (Evaluation methodology, clarification of how decision-niaking would I)c,




                                                                                                                  -3                                        Pll  00019            7   7 0    I




                                                                                                                                                cl  Corporation
                                                                                   E@t@frinii-iaL.i-oii  of  what  Lo(,kfie(!
                                I             -I-  @)t-t                         CVE'L. @)pmen t       and      "d e - bugg ing

                                                                                                I
                                 I-  C          iicl n       ii                  s i@ L (@@  t eaiTi,  wli i- c @i  wa s   c oi-ic urr ed   i.n  by
                                                                           was  a  ret--irn  for  revision.


                                                                    bc@l.ic,.@ve       tliall-       they       have        amply        provided        for        the
                         ]act-<                                   -in            original   proposal  by  establishing  an
                                                                                           nurses,   scientists,   and  outside
                         .id
                                                                                        and  analyze  all  pertinent  data   for
                                                                                                       evaluation  in  a  clinical  setting
                                                                                 I                                                                                  "f a Ise"
                                                        S L Li   17              11.  @3l.gnal.s  and  alarms,   specifically  1)
                                                                                       -.iTid   '.3)   true  alarms.

                                                                                         evaluation  will  be  controlled  by  trained
                                                                                          'tariL  electrocardiograms,   and  by  long-
                                                                                 n ,', C)I'i 1 i-



                         A                          al@@o                        of:   1)  alarms   indicating  a   life  threatening
                                                                        il-,@ri,ns   I.eading  to  improved  patient  management.
                         In  e@i(-,It               t:Jic,                       decisions  mad(,,  by  doctor  or  nurse  will  be
                         tabijlar(,(,,                                           At  4t--Iie  same  time,   evaluation  of  the  impact
                                                                    1 (,T@ L     population  will  be  examined,   not  for  mortality
                                           d i          l@ or-i c,-  1-@i-i t    alsc)  for  psychological  effects.                                  The  impact
                         on                                                      a@@   @-o  acceptance,   assessment  of  the  usefulness
                                                                     c,    r!    [ect  on   the  care  of  the  acutely  ill.  patient


                                                 1) i                      I     I             direct  resp(-)nsibility  for  all  evalu-
                                                     C"":                                                       a  N@irse  Director,   Cultural
                                                                                                     Statistician             and             Data             Analyst.
                                                                       cjL-@L@c@r       tliree       years       federal       funds        will        not        be


                                                                                             to  provide  monitoring  for:   1)   coronary
                                           af ter  tlir,i),-                            frorit  an  existing  CC[f,   2)   patients  who
                                                     cii-  s                      from  acute  myocardial   injury,   3)   paLi.ents
                             -i@ 1)   @l I i @2,  ja 1,@ y   @ v F)                              and  /@)  patients   in  the  hospital  who
                                                          )Tr,,,   any   i,i              or           surgical           disorder           which            carries
                                                                  l@,,           iiia(lecluate  coronary  circulation.

                                                                                 T)ropo@;al         is         an          educational          and          training
                                ri            1)(,,i      -  @@  I  1,  @  I
                         T@@ r             ()Y@  I)I@y:@                   r,urse,;  ancl  other  personnel.                              The  course  will
                         @i. II i-i ri                                                             of  acute  care  for                   patients,  whether
                         t                                                       t@,r  c@ii  the  @@eneral-  floors,                      Special-   training
                         in   t:ti,  ii,,c,  @)f@                                  w@i.11.  occupy  approximately  one  half  of  the
                                                     @iiici  dirin@,   LIIE@S(@2  peri.ods   there  will  be  practical   experience
                                                                                 patients.               The            educational            and             training
                                                                                   1,711-t@        the        existing        Area        I        coronary        care




                                                     -4 -            Rm  00019 7 /70. 1
           (,ALIFOR-NIA Medical Education
            and Research Foundation

           The training courses will be tailored to the needs of the  learners
                                                               Courses will  be
           of whom there will be 16 for each one-week period.
           given four times yearly.  The project will not be extended to
           participating hospitals until about the 22nd to 28th month of the
           program when an installation of the second 20-bed unit will be  made
           i-n the Vallejo General Hospital.  The third will be the General
           Hospital of Eureka,California, 280 miles from San  Francisco.  This
           facility has 103 beds, no acute care unit, and no house  staff.  This
           unit will be installed and implemented by the 30th month of the grant.
           The budget requests funds for providing for the construction and
           installation of the first 20-bed unit, and the educational  training
           components at Mt. Zion Hospital and Medical Center. The budget  alslo
           includes items for anticipated costs in further development and
           de-bugging of the system,
           llreliminary testing was carried out at Mt. Zion Hospital and Medical
           Center by means of a model financed by research grants from Mt.  Zion
           Hospital and Medical Center, with contributions from Lockheed Missiles
           and Space Company (approximately $56,000).
           The surveillance unit may be available for purchase, installation and
           maintenance at a cost which will not be prohibitive. The  units  will
           be capable of monitoring any desired number of patients  for  about
           $1,000 a bed, and maintenance costs will be approximately $48 a  bed
           per year.
           The statement included in the Appendix entitled "Why Lockheed"
           documents the reasons for the selection of Lockheed Missiles and
           Space Company to develop this project.  These were based upon the many
           years of research and development programs and in space-related efforts
           for the military and NASA in which the Lockheed Company has designed,
           developed and utilized medical monitoring equipment of all types
           ranging from sensors to complex signal  processing  equipment.  Also
           Lockheed has long experience in producing modular data processors with
           the aid of integrated circuits, without'which the system  could  not
           have been developed.
           Second Year:  $227,156                           Third Year:  $260,309
                                                                                     Requested
           Project #60 - Medic lL ILnifoiramiicatit-ion Services - Area VI.'This program is irst Year
                         based on a pilot program initiated in cooperation with       $39,388
           the Area VI office and committees to develop Regional Medical Libraries
           Information Systems, linking the major medical libraries with each other
           and with hospitals within CCRMP so that information is readily accessible
           to all health personnel.




                          CALIF.'C)RI41A                                                                                                 -.5                                       RM  00019                 7 /70. 1
                              and



                          In                                                                                                         information  resources
                          and                    services                                                             ')ouLlt-"Yest  Region  (States  of
                          Arizona, C@i Iifornia, H                                                                         a)   was   conducted   by   the
                          Directc@r   of   Lil)rat@i-ec,,                                                                                         The                survey                revealed
                          that  Area   V,'@   of                                                                              is         one         of         the          most          backward
                          areas   i.ii   the   Southwest                               s   re                   i,,)Ie           -Lc@il           library           resources            and
                          services.                  @,!(,)st           me('I-'.(,a-i                                                  are                    extremely                     inadequate
                          in         Area          VI.    The              @r-egioy@,                       @-o           i-i,,-,-@-hen.            the            most            important
                          single            @oui.-ce             of                                                                       -Ls                personal                medical
                                                                                                                                   range   of   general    journal
                          literature                 through                 a                                                     I'@i-Ls              will              bring              information
                          directly                  to                                                                                                the              four              counties
                          of         Area          VI.


                          A             major              resource                                                                and         tl)is         is         also         a         MEDIARS
                          Stati-on.               A              telel--y@-)c-                     I-).@      D.@@,ii           Installed           to           provide           a            direct
                                            little           I,)etw                                                   '@C;j'-,A            Biomedical            Library            to            give
                          @i   reasonable   speecJ,    arid   (@f                                                                                     loan   service.                      The
                          UCIA  Bi.orn(-,cl:i-(-al-  Lil.)rar,                                                                       Library             for             the              Pacific
                          Southwest                 Region)                 is                                                       @lo.          Z@8.     It  was   also  developed
                          as   a   result   of   a   pilot                                                                    @r.@our                  district                   libraries.
                          The             proposal              was                         for                               when                the                original                operational
                                                        was first                                             'DuL-             was             revised,             resubmitted              and
                          subsequently   approved.                                                                    ecl-udes              Los              Angeles              County              which
                          is   covered   by   a                                                               by          @l-lie           Los           Angeles           County           Medical
                                        ssoci-eitio@@l                                                                                 will             not             duplicate             any
                          services r@r@)-,,7idecl IDy                                                                              .1   i    brary    ,    but    it    is     be     I     i     eve     d
                          that             RM1.1             services                                                              stren,,@,L@iene(I   through
                                                                                                                                             new   library   service    will
                          cooperation between t@  ii,@,
                          be   @t   vital   back-i-ip                                                                              ..,c)iiia   Linda   University  Library
                          can  refer   @r.-eque,@,,ts                                                                         i.rc)-cii its own resources.

                          Area        'VI         wi.l..t                                                               C,    s    -OIL@@            for            lic)spital            library
                          per            oiiriel-,,               rlt              @f-                                                    has          prepared          a           manual           of
                          library   r@roc@clires                           @l'         7@

                          it       is       @Dr(-)P(:@@3ed       @..o                                                              @@@l            ,.-,,uccessful             Current             Aware-
                          ness   Servi,..,-@,   togeti@,@,.@                                                                       @@@i@o@o(,c)py   service,   while
                          commencing                    a                              e                                      ,.@.i@-L(,ations Service.

                          "F h e @.@i rc!,-, 1. t h p i:  C)  f  E@          I                                             @L-o              Linda                    University                    Library
                          by       niai.J-       or                                                                                   )f            a            specific            journal
                          article.                               i.';                                                                        @--nd          rae@ilc@cl          as          quickly
                          as                 POF@s@.bi;,,        If                                                                             f.,onika          Linda,           an           inter-
                          library                    loan                                                                   l@,      c)            The            UCLA            Biomedical
                          Library.                A                                                                           s    @lil.sc)   offered   as   another
                                                 of


                                                                                                                                                t.rLi:i.c@ed librarian will
                              s i, t@       o s p i -L@ a    s    @@7        i.@,,                                                                    three  times  a   year




         CALIFORNIA Medical Education                  -6-             RM   00019  7/70.1
           and Research Foundation


         to encourage and assist  in  establishing  medical  information  services
         in hospitals where  none  exists.  A  bimonthly  or  quarterly  newsletter
         will convey information and exchange  ideas  among  all  hospital  adminis-
         trators and library personnel within Area VI.

         Continuing education courses  and  training  programs  for  professional
         medical libraries throughout the Pacific Southwest is planned as a
         part of the ongoing project (#48 - RMP Library), and all medical
         librarians located within Area VI  will  be  encouraged  to  participate
         in these programs.   The region has  identified  three  potential  areas
         of future support from non-federal  sources:  1)  subscription  basis  on
         the part of the health professional; 2) support from individual
         hospitals; and 3) support from voluntary health agencies, county
         government,  private  philanthropic  organization,  industry  (especially
         pharmaceutical), local service clubs, etc.

         Evaluation will utilize data from a number of sources, such as
         statistical records at the Loma Linda University Library to show
         clearly the extent to which each service  is  utilized.  At  the  end
         of the first year a questionnaire will be niailed to  all  that  have
         used the services offe-ed. A  Field  Consultant  will  be  constantly
         in contact with hospital library staff  and  to  some  extent  individual
         practitioners.   Hospital personnel also will  be  invited  to  evaluate
         the services available to them, with  emphasis  on  the  consultation

         service.

         Second Year:   $46,797                          Third Year:   @49,975

                                                                                       Requested
         Project #61    Integgraded Assis-La-its Program - Area III.  This  is  a      First Year
                        three-phase program developed  by  the  Stanford  University    @232,676
         Hospital in cooperation with the Foothi   1 1 7unior College  and  community
         physicians.   The program has been discussed over  a  two-year  period  and
         reviewed and approved by the Sa-@ita Clara @IP  District  Committee,  the
         Stanford Faculty RMP Advisory Committee, the  Area  III  RYIP  Committee
         and the California Committee on @ .     The project  represents  a  commit-
         rqent on the part of Stanfo@University Hospital to broaden significantly
         its effort in the training of allied health manpower.

         Phase I has already been implemented  with  support  from  the  Stanford
         University Hospital and the Carnegie Foundation.     Stanford has provided
         approximately $20,000 annually for personnel and the Carne-ie Corporation
         $65,000for the pilot study.    An add-@'-L-Lcnal request of $56,000 for imple-
         menting Phase 3 of the prooram has been made.

         Phase I deals with a coi-nr)utc-,riz--d educ,-.t@--,)iial program des-'-,-Ined by the
         Stanford School of Education and  made  available  to  hospital  employees
         (chiefly from minority groups)       wish to complete high school
         requirements.   It also provides on-@Lhe-job ouidance in learning
         facilities, including a compute,.-           dedicated to self-instructional
         programs.   Upward mobility into Phases 2 and 3 from  the  bottom  of  the
         health career ladder is made possible 'D3, Phase 1.                                   1,@,.:@I





                                                                                                                                                                                                       RM 000 19                   7     70. 1




                                  P life s e                                     @ip[ 0                                                                                          c@@)tirs e  f or
                                                                                                                                         t                         L:@)y,y  ani::i  14  months
                                                                                                                                                                   s             (,,ve@ry three
                                                             40                                                                                                    @l            @-'()tirse i,n ftiiida-
                                                                                                                                                                                 1),                   pr@icticaL
                                       k,                                                                                                                                                ot-[(,       of        a
                                  vri I' i c, I-     k)f         11                                                                                           I        I)        ilot       pro,,,raiii        oi.
                                  ti) i      L,,l  p  c,  I  i        a     r-                                                                                                         the                     support
                                  of   t@if    LJrl)af:i                                                            i       7                                                    Liti@i,s course are
                                                                                                                                                                                 tor,[s @   Phase   2   may
                                                   loyc@@cl          c,   t i 1 1-@l@
                                  t)(@!            a            sLeppii@g-.Stc)@-i              11                                                                               programs    lead in@,


                                                '3

                                                                                                                                                   L               II)           ,I y  k@/  i  L  I  I   'I   in   i   11
                                                                                                                                                                                                                  WL11
                                  be                                                                                                                                                                     lieaLtli
                                  p (! I:, 0 i-i      I      li@(Ici      1                                                                              i (@i                         @,!i,tli   nort-rfiedical
                                  backgr-@.@@iiids                        I                                                                              1) r      i             i--ca ii g c.@   o f   p ra c t ic a I
                                  c @-i p,,i t) @i I- i t i c,        i r@ cl     i:@@  I'                                                                                       i I) ly            arranged             in


                                                                                     (@l  l-,@  I                                                                                @-o,,2ram   for   qualification
                                  t I @. r o ti              (i   t   i   -f-@ a I   i                                                                                               is   a   physicians
                                  @'i s s is    @IrLt             1)(@,@c                                                                                                            i.i-.ij--ensive   coronary
                                                                                                                                                                                                ma terna I   and
                                                                                                                                                                                                                     -type
                                                                                                                                                                                                             residency


                                  Ti@c,                           1)@.ii      Ld,,                                                                                               i    i-9@)@i   by   a   program
                                                                                                                                                                                 i. ecl   ])ea L tti   pos i t ion s
                                                                                                                                      r       I", s



                                  r
                                   i t [I f@  I  I  c@  11  t@@  1  T)  o  -f                                                                                                           Sc,@iool                   and
                                                                                                                                                                                 @@A  curriculum was
                                  c'rafti",@] ari(-i @i l@,@                                        i--                                                                          '19()8          Keith           seven
                                  iii i. ii or  j.  t@N,  F,  t,  jd  eii  t@         -I l@                         I                                              @l            service         staff
                                  @it   tl).(-@   i@,le@iical   Cc-,ckL(-,r,                              t         @,iii             1                         i)               ei.r,L classroom and
                                  laboratory
                                                                                                                                                                                 l@>I.aced           in            the
                                                                                                                                      I"                     i'@                 To Altc)   Neighborhood
                                                    (,,enter   fc).r@                                                                                                            4 ii -in g. At    VI-ie   end   of
                                  C I i s        c@ r @l. o  cl  a  @'I  @L                                                                             I  L  .@l  r             E@Inp    I-c)@    ee,@     at     the
                                                                                                                                                                                   training.

                                                                                   ()f                                                                                                              hospital   and
                                                                                                                                                                                 ,(inin@ir   tyroups   to
                                                                                                                                                                                              @minori.ty   group
                                                                                                                                                 L                               l')c@@c@@irtmerit was          formed
                                                                                                                                                                                 hospital   jobs;




                                                                        RM 00019  7/70.1
           CALIFORNIA Mc@dical Education
            and Research Foundation


           2) develop training programs for minority persons in the Medical
           School and the University Hospital; 3) promote harmonious intergroup
           relationships within the hospital staff.
           By April 1969, the Intergraded Assistants Program described in this
           application was develo@)ed as a result of suggestions requested from
           the various departments.  It is not directed exclusively at disadvantaged
           or minority groups, although the program will provide unique  opportunities
           for them.  The program does envisage the creation of new careers in the
           allied health field and the provision of training programs designed to
           facilitate upward mobility into these careers.
           Phase 2 will concentrate on the training of health technology assistants.
           A high school education or its equivalent will be required for the
           approximate 40 persons to be trained.  Two hundred interested recruits
           out of a possible 240 minority group employees of the Medical Center
           have expressed interest in participating in the program.  One hundred and
           forty of these have an educational attainment of tenth grade or below
           and are appropriate for Phase I education.  Thirty of the others are
           now holding semi-skilled jobs are interested and appear to be candidates
           for training in Phase 2.
           The initial eight weeks of training will be spent in laboratory
           instruction at the hospital.  Instruction will be by means of lecture
           and reading assignments in several standard textbooks.  Tutorial-type
           sessions with individual students or pairs will be arranged.  Various
           experiments with discussion and interpretation of material, as well as
           individualized instruction is planned so the trainees can prepare for
           their specific assignment when they move to on-the-job training.
           Trainees can participate in parts of Phase 1 while enrolled in Phase 2.
           lqhen students complete laboratory instruction they will be assigned
           to various appropriate specific locations in the Medical Center  for
           four months of on-the-job training.  They will work under the direction
           of medical and health professionals and skilled technicians, who will
           instruct in a one-to-one manner for improvement of specific skills and
           tec niques.  Following training students will be assigned as follows:
           fadiologic technologist, radiology nurse, X-ray service  technician,
           inhalation therapist and technician, etc.  During this portion of
           training these students will act as aides or assistants to the professional/
           Lechnical personnel.
           Students will be paid by the project during the two-month training
           period a rate of $400 per month.  A further alternative for trainees
           is the opportunity to participate in an occupational training program
           in health sciences at DeAnza and Foothill Colleges in technical
           specialties.
           The Phase 3 portion of the application deals with the training and placement
           of Physicians Assistants.  This involves 20 months of  intensive  training-
           Candidates will be trained largely by physicians to be a  highly  competen@
           extension of the physician's technical arm in certain designated  areas  of




                                                                                                                                                                               RM      000       19     7 /70. 1

                              a i-i. (I I'@ c@ f@@,q i- r-t                  'i'@



                                                                                                                   I)Iiy@@         i,@iiis .     (,la,-,ses will  consist
                                                                                                                                        on  Admissions   and
                         (;r@i (ii                               i          @ri                                     i-@-ic(ii.i@y            pl@ysi(-@i.ans,             ,,I             physicians
                                     t  I  r-I    i ri S L r I].(  t@                                       'I L@ a t@@ i @7 (@ F, () f tlic,  a I tied   liea I tli
                           pe(@ i,'@ I t i,                                                                       @@@ic@   (,c)ii.c@tirners           of               health                services.
                                                                                                                      and                recommended                bv                supervisors
                         or           OLIICI@@      r    0 ii. s                                      I-  i-)     ii               school   diploma   or   its
                                                                                                            1      @@p(,.ri(iice         of         at         I-east         two          years,
                                                                                                                                  2.

                                                                                                            i1      c@ri          tli(,,:!          Sc@liolastic,          Aptitude          Test
                                                                                                                                   ']'est   of   the  College   Entrance
                                                                                                                                        character                  references                   and
                                                                                                               i)@                    evaltiati.(>il   by   the  Committee
                                                                                                                                     receive          a          stipend          of           $400
                         per                                                                                                1-@-I         tl)e         need         for         continuous
                                   S f.@.,L i r@                                                                       @.tisti-uctc)r.,s   as  well  as   the
                         1) ()  s            E@   c@       I- L 1-1, Ti
                                                                                                                            p(@rsc)iin(:,]-             department              and              other


                           li   e    i@,t r- i- i. c@ i-i.II                                                                       pai- Ls     consisting  of                          one
                         @/ear   (i@                                                                                        @fie,,i     @i-ca      I      theory      with      emphas      is
                           p (.) l@   t@ I I      r",l c t@ i   a                                              a @)s t.-rac t .           TI@iis          will           be           followed
                                                                                                                            practice                   through                    assignment
                                                                                                                         r..@ent-er.    The           final            segment            will
                         (,.c)nj:;i,@,t   c@f                                                                        i-r)           a           specialized           area,            working
                         ti    nd                                       0 1                                                 a               hospital.               situation,                doctor's
                           f7 f i                                                                                   ro@)rit.         A.           detailed           outline            of
                                                                                                                      @).I-           @@@t@iL-id@ir(lizatiori            will            occur
                           v  c- @@i  t      @'LY,    i-) t                                                    F)
                                                                                                                                   @i(it@l@iors        feel        tiiat        it        is
                                                          I tA  I I i@@ @,i                                      @r.,  oa   c      i @   o r d (@r   t o  a cl a p t   t li e
                                                                                                                 of                program         on         tire         basis          of



                                                                                                                            11,C)t@           licensed           i.ii           California
                                     t@     i,         i@    I        f -1                    i           for               Lo           be           employed           as            assistants
                         to                                                                             @@Ls          1.@1.1@el.y          that          legislation          to           permit
                           L i  t@  i@    t  i C-@ r,   0 f     I i.11@,@@ 'L (2 I' @A                                             be          passed          in          the           California
                                                                                                               'L@l'ici         before         the         graduation          of          the
                                        (.:.laws   Fr,-)iii


                                                            LI    1),@,
                                                                                                                                   @,71ic,,ther          it           is           achieving
                                                                                                                            health  manpower  and
                                                                                                                      o,,@@iLy           @iroup           persons           and            others
                                                                                                                                          occup@it@[c)tis .                                 Evaluation
                         of                                     @L@i                                           c@         cor@t:iiiiic)iis         basis         in         order         that
                                                                                                                      I:)@-            desi.aii(-,d            and             implemented
                                                                                                                            i-)@.iiiiber  and   background   of   trainees
                                                                                                                       @-itei.i-   @iccept@@ince   in  new  positions




           CAI,IFORNIA Medical Education             -10-             RM 000 19  7 /70.1
            and Research Foundation

           after graduation.  Other evaluation measures will involve student
           progress (in all phases),-job performance, continual feedback and
           a final summary of evaluative analysis.
           Program direction and coordination will be the responsibility of
           the program director to be assisted in various administrative
           functions by the Minority Relations Department.  Evaluation will
           be directed by Robert Heath, Ph.D. Associate.  All instructors
           responsible for Phase 1, 2, & 3 have been identified.
           A number of methods for public and professional information will
           include a lecture circuit for physicians in CRMP Area III to reach
           physicians via county me dical society meetings, specialty group
           meetings, etc.
           Second Year:  $231,940                      Third Year:  $239,039







                                                   CALIFORNIA Medical Education                                                             RM 00019         7/70.1
                                                      and Research Foundation


                                                                             02     Operational     Budget     Period      Support
                                                                                          (14 month period)



                                                   Core*


                                                                    CMERF                                                             54,931
                                                                    Regional Office                                                   373,635
                                                                    Area1                                                             634,640     (Includes
                                                                                                                                                  $6,500 02Sl)
                                                                    II                                                                244,854
                                                                    III                                                               354,244
                                                                    IV                                                                802,288
                                                                    v                                                                 646,993
                                                                    VI                                                                198,664
                                                                    vii                                                               224,649
                                                                    viii                                                              225,104        (Includes
                                                                                                                                                  $10,000 02S2)
                                                                    Project #35  (Area IX)                                            185,464

                                                                    TOTAL                                                        $3,945,466

                                                   Area             I


                                                                    l@ I-Coronary Care Training       Area 1                          312,792*
                                                                    @kl5-A Regional Cancer Program                                    330,610***
                                                                    #18-Training    of    Physicians    in    Intensive    Care    for
                                                                    Small Hospitals  (Pilot Program - Pacific
                                                                    Medical Center)                                                   ii,ooo**
                                                                    #20-Hypertension - Area I  - Northwest Calif.                     362,070*
                                                                    @i25-A    Proposal    for     Rehabilitation     and     Continuity
                                                                    of Care Services                                                  187,061***
                                                                    #26-Intensive     Training     Course      in      Cardiopulmonary
                                                                    Resuscitation     for     Emergency      Rescue      Personnel    10,634-*
                                                                    ,@27-University    Medical     Center     -     Rural     Community
                                                                    Hospital Demonstration Cooperative Program  in
                                                                    Primary Physician Training & Continuing
                                                                    Education                                                         92,981-**
                                                                    #55-Solano    Supplement    to     Program     for     Rehabilita-
                                                                    tion & Continuity of Care Services                                Approved  3/70         LinfLinded

                                                   Area             11

                                                                    @k 2 -Roseville Pilot Program                                     92,145*

                                                   Area             IV


                                                                    4 -A Training Program for Physicians  in Coronary
                                                                    Care Cedars-Sinai Medical Center  (UCIA)                          236,192*
                                                                    #7R -RMP Medical TV Netweork - A Center for the
                                                                    Continuing    Education     of     Health     Care     Profes-
                                                                    sionals Using Television and other Audio-
                                                                    visual Materials                                                  392,000-*
                                                                    #24 -San Fernando Valley and Pacoima Health
                                                                    Planning Project                                                  160,890-
                                                                    #58-Training Program in Coronary Care                             Approved 3/70        Unfunded

                                                   Area             V

                                                                    #11-Program for Training Physicians and Nurses
                                                                    in    Coronary    Care     Techniques                             483,281*
                                                                    #23-Chronic      Respiratory      Disease                         113,913*-,@*
                                                   Area             VIII
                                                                    Y@21 -Pediatric    Pulmonary    (U.C.     -Irvine)                206,520*
                                                                    #28 -A Comprehensive Stroke Program                               370,802--
                                                                    (Transfer of $29,259 from indirect                       @ing)
                                                                    #54 -Rapid Hospitalization for Acute Myocardial
                                                                    Infarction                                                        Approved
                                                   Area            IX
                                                                    #6 - Watts-Willowbrook Post-Graduate Education                    498,314*
                                                                                                        TOTAL                    $7,806,671
                                                   *                commitment  for one future year
                                                   **   no future commitment
                                                   *** commitment for two future years

                                                                                                                                           DRMP/GRB/5/14/70




                                          . 4

















          - 0
                                                                           0                                                              0









                                REGIONAL MEDICAL PROGRAMS SERVICE,'
                     SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                    (A Privileged Communication)

              CALIFORNIA MEDICAL EDUCATION AND                       RM 00019 7/70.2
               RESEARCH FOUNDATION                                   June 1970 Review Committee
              693 Sutter Street
              San Francisco, California  94102

              PROGRAM COORDINATOR:  Mr. Paul D. Ward

              Requested
                 ram
              Period             lst Year          2nd Year        3rd Year         Total
              Direct Costs       $77,307           $77,248         $81,393            $235,948
              Indirect Costs        1,467            1,542            1,571              4,580

              TOTAL               $78,744          $78,790          $82,964           $240,528
              HISTORY:  This proposal was reviewed 'by February 1970 Review Committee
                        and March 1970 Council and deferred for additional information
              concerning its relation to CHAIRS, a project in Los Angeles  County
              approved by  the  Council,  but  subsequently  funded  by  the  National  Center
              for  Research  and  Development.  Notes  concerning  an  expert  review  of  the
              two projects are attached.
              Project #56 - Community Resources and Information Services                St   Year.
                              (CRIS) - Area VIII.  This project proposes to               $77,307
              create an organization which will make available, through one
              telephone  call,  knowledge  of  all  the  community  services  avail-able  to  the
              caller in Orange County.  It will establish a ric,ri-profit Community
              Referral  and  Information  Center  to  be  professionally  staffed   and   managed
              to assure continuing and improving service to all the people.  The
              Community  Referral  and  Information  Service  (CRIS)   will   identify   resources
              for total  patient  care  in  the  broadest  sense  to  meet  the  physical,  social
              and  emotional  problems  of  the  patient  and  his  family.  Its  services   will
              be available to all members, professional and lay, of the community.
              This program is similar to  one  which  was  reviewed  bv  a  si.te  visit  team  in
              ,July 1969, (CHAIRS  Pro  ect  #30)  and  subsequently  received  approval-  and
              recommendation  for  funding  by  both  the  Review  Committee  and  the  National-
              Advisory Council.
              Such a service of information and referral will. contribute to regionalization
              by  (1)  identifying  needs  and  opportunities  for  thei.r  solution;  (2)  coord-
              ination of  the  RMP  with  other  activities  in  the  Region;  and  (3)  providing
              the Region with a continuously updated inventory of existing resources and
              capabilities.
              This  project  will  provide  a  coordinating  body  for  the  numerous   community
              service  organizations  and  services  providers.  There  are  large   gaps   in
              services and under-utilizat@i,c)ri -;f many of  the  existing  ones,  and  there
                                   . .  -- -.r. --- - 1 -1           ,@ll -n-rr)@7irlp information




            CALIFORNIA medical Education             -2-                Rm 00019  7/70.2
             and Research Foundation


            and referral services to make known all available community resources
            in Orange County and coordinate with a network of referral programs in
            Los Angeles County.  The service will be available on a 24-hour day,
            7-day week basis.
            It is hoped that the program will act as a catalyst to existing agencies
            in the action required to fill in identified gaps.  Periodically, a
            directory will be published to guide the delivery of health, education,
            welfare, vocational and recreational services in Orange County.
            The program emerged from planning of an ad hoc committee, which includes
            representatives of the Regional Medical Fr g@rams, Area VIII, the University
            of California at Irvine, Orange County Health Department, the Medical
            Association, Chapters of the National Foundation, Tuberculosis Association,
            Heart Association, Cancer Society, the Medical Center, Mental Health
            Association, private industry and others.
            In May 1969, an ad hoc committee on incorporation was elected and a charter
            of incorporatio@iq;s-drawn up.  Articles of Incorporation and approved
            Bylaws were formally adopted September 16, 1969 and are included in the
            application.
            The Co  unity Referral and Information Service will operate under a
                   mm
            Board  of Directors.  A technical advisory committee, made up of
            representatives of various professional disciplines will advise    the
            CRIS board and the executive director on programs and policies.  An
            executive director will be hired by the Board of Directors.
            Funding through the Orange County United Way will be requested as well
            as other funding sources explored.
            Evaluation measures will be readily available from the beginning of the
            program and will be reflected in an increase in the number of referrals
            and the increase in the willingness of local agencies to assume financial
            support.
            The statistical reporting system presently in use at the Los Angeles
            Welfare Information Service will be utilized in the early part of the
            program.  This is a tabulation of the media for the initial inquiry,
            its source, types of problems, kind of service provided, the community
            in which the person with the problem resides and the referral agency.
            The records per se of CRIS will be another form of evaluation of the
            project as well as a follow-up of calls.  As volume increases, evaluation
            of a random sample of calls planned and controlled for accuracy will be
            utilizp,d by the usual and accepted statistical techniques.
            2nd Year:  $77,248                        3rd Year:  $81,393







           CALIFORNIA Medical Education        -3-              RM 00019 7/70.2
             and Research Foundation

           Review Committee, February 1970:
           CRITIQUE: The Committee found the project to be well  planned  for  an
                      obvious need, and noted that the project will become self-
           supporting in three years.
           The question was raised as to the degree to which the source o  t e
           information can answer questions, and does the process in fact bypass
           the physicians? This in turn raised the question of  the  legality  of
           such bypassing.  It was also noted that California has the highest
           number of malpractice suits in the Nation.
           The similarity of this project to one previously reviewed from this
           Region (CHA-IRS - Project #39) was recalled and it was noted that  the
           National Center for Health Services Research and Development has
           funded this project for a five-year period in the total amount of
           approximately $700,000.  This program is based in Area V (USC).
           In view of the decision to fund this program by the Sanazaro group, the
           committee agreed that perhaps a deferment of the decision  to  approve
           would be in order until we are able to evaluate the success of the
           CHAIRS program.
           RECOMENDATION: Deferral for further information subject to expert and
                           indepth review in relation to the CHAIRS project in order
           to ascertain if it is (1) worthwhile; and (2) justified for funding under
           PM.

           National Advisory Council, March 1970:
           Council reviewed additional information from CMT, but requested infor-
           mation from an expert in thefield of information and referral services
           on the comparison of CHAIRS and CRIS.  Action was deferred pending this
           information.
















                                                     DRNP/GRB
                                                     June 4, 1970





                                             OF HE/,I-:f@1--I, EDU@-A-f-101@,
                                                              SEI-@VICE

                                FIEAL'f-ll @El-@'VIC,E@-@ A@41:1



                          1970



                Tel-ophoi-io Conversation with Miss Eileen Lester,        Comprehensive  Hc--al-tli
       Szi,@ject: Services, Concerning Her Review of the CRIS Proposal- #56 from Area VII.I,
                California P,@IP
          To:
                For the Record




                Miss ],ester  was the project officer from one of         the   initial   infornia-
                tion and referral services (in Rhode Island) and has provided
                consultation  to  the  majority  of  1.5  programs   funded   under   a   Community
                Health Service contracts since then.  She had re@Viewed both the
                CHAIRS  project  in  Los  ATigel-es  County  and  the  CRIS  proposal  in   Orange,
                County.    I called her to request specific information about the
                questions raised by Committee .ii-id Council regarding relationships,
                similarities and differences between the two activities.                 Following
                are her telephonic comparison of these two projects, her comments
                about  strengths  and  weaknesses   of   the   CRIS   proposal   and   information
                about experience, with other information and referi-@il- services:

                      (1)   The basis objective of both CHAIRS and CRIS is the same: to
                establish a Central- Information and Referral Service.
                      (2)  -The methodologies employed are different            the CHAIRS project
                is CODCC@rned with the application of computer technology to the process
                of referral and will utilize a i-7ell-establisbed Information and Referral
                Service.    The CRIS proposal- wo@cl employ stai-iclircl accepted and Provo-II.
                techniques in developing a new service.

                      (3)  l,.ach  project  is  unique  iii  its  own  way.  CHAIRS  is   a   research
                and development activity which is experimenting with computer technology.
                The  CRIS  project  is  a  seed  activity  for  an  essential   component   of   a
                comprehensive  health  program  in  one   of   the   fastest   growing   counties   in
                the United States.      The County has, iiid will continue to have limited
                resources  which  must  be  utilized   to   full-est   effe'ctivei-iess. The    County
                Health Departii-,C-,nt  has  a  very  competent  heal.tli  officer  who  is  unusually
                cooperative toward the medical- school- and the )-.\Iegiol-ial. I.',c-,dical. Program.
                Project  planning-  has  resulted  in  commitment   from   an   array   of   community
                agencies,               i,i)dLi   .  The number and viri-e-t@yof agencies involved
                                        @CILI t@ry-
                at the planning stage is      unique in Miss i,ester's experience.
                      (6)   The fact tliac CHAIRS is locate     cl  in  Los  Angeles  County   and
                CRIS in contiguoi-i  Orange County is an advantage since the CRIS








                For the Record
                Page 2


                persoi-inel i-7ill. have ttic@ benefit of coi:istiltat@l..oii, from CI-11@lP@S, iiid  will
                be  able  to  utilize  basic  information  on  Los   l@iigc@-I.es   County   fac@i-l-itics
                which serve Orange Cou,-)ty rc-@sicleiits i-i-icl ii--iforiiiatioii oi.-i any Oraii-e
                County facilities that Los An-cles residents may use.                  Miss Lester
                indicated tli@-tt    a provision of thc@ li@tiiig aloiic@             save six  ll,,ontlis
                tiTtie for CRIS qnd           enables them to pursue new agency inforiiiat@ioii.
                Even  more  important,  she  said,  was   that   the   Los   Aii-eles   prograni.   has
                evaluated  the  age-,icy  information,   a   process   vTli-i-ch   usually   takes   Ibout
                two years to complete.

                       (5)   Miss Lester did not see any advantage in withholding a start
                on  CRIS  until-  the  CHAIRS   project   is   coiTTleted   because   CHAIRS   is   a
                three--year   research   and   developirient   activity    in    computer    technology
                which i-,)ay or ipay not be applicable fo3-                County with only a 1.4
                million population.

                       (6)   The  strength  of  the  CRIS  proposal,   Miss   Lester   fc,@elo,   is   the
                creation   of   a   basic   service   under   Regional   Medical   Pro-rain    auspices
                i@ihic@li  can  assure  the  provision  of  pi.-ofessio-i-iil  and   medical talents.
                The i-Le@,7ncss of the  TJi-iivcrsity  Medical  Center  and  the,  I-,nowii- con-amitiiie-nt
                of coi,@Lunity agencies augtir             for its future.

                       (7)   The  Tiiajor  weakness  of  CRIS,  she  felt,  was   ii-i   the staf:fiiis
                proposed.     She  felt   that   more   tim@   of   the   project   director should be
                devoted  to  building  fi.rrii  working  relationship--  with   the--   c@oiti:munity
                agencies and in,-"clical profession.        She felt tlso that the second posi.tion
                should  be  filled  by  someone   with   experience   in   con,,iiiii-ii-ty   organization
                rather than in ciF,(@ i.@oi-l-,.   The eTnl)l-ia.sis of staff should be on developing
                the   service;   the   cooperating   agencies    should    provide    any    individual
                case work.

                       (8)   Miss Lester says that i)o other source of funds are available
                for developing central information and referral services.                   Experiel-ice-
                with 15 contract projects has been that all have- bee-i-i iyt-aintained througl-i
                community resources after three years of i-iiitial su.piDorL.               Tjnited
                Community Funds have been the principal source for                                  and
                the  Funds  will-  not  support  the  initiation   of   a   service   -until   it   has
                been   tested   and   pro)7ed   effective;   furthermore,    the    initial    expenses
                in developing and evaluatiiag referral inforniiti..oi@. are barriers.
                       (9)   Miss l,estc@)- indicated PIic,  would  be  gl..-,cl  to provide- consultation
                to Cl@@@J.-S.




                                                                                   , @'C'
                                                                         I/Sir,,i.11 11'. Silsbee
                                                                           Acting      Chief
                                                                            Gi@@aiit-, Rc@vic.@,7 Brincli
   0




                                                           (A Privileged Communication)






                              S     Y OF  REVI'EW AND CONCLUSION OF
                                   JUNE 1970   VI:EW CO@RIIITTEE


                             CALIFORNIA REGIONAL MEDICAL PROGRAM
                                     RM 00019 7/70.1 & .2

                       FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


             General: The California "package" presented at this review cycle
                      consisted of two new operational projects and a revision
             of one (#41) previously submitted but returned  with  suggestions
             for specific revisions (7/70.11 plus another proposal (#56) which
             was reviewed by February 1970 Review Committee and March 1970 Council
             and deferred for Additional information concerning  its  relation
             to another similar program in Los Angeles County, approved by Council,
             but subsequently funded by the National Center for  Research  and
             Development. (7/70.2).  The combined direct cost budgets request $613,200.
             Project #41 - Area I - Patient Monitoring

                        The Review Committee noted the technical concerns raised
                        by the Ad Hoc Cardiovascular Study Panel, particularly
             the support of a 20-60 bed arrythmia detection system before documenting
             such a system in a one or two bed "live" system.
             The reviewers believed the objectives of the project-to be
             clearly sta ted, although their attainment within the time proposed
             was thought to be problematical. The failure of the region  to  submit
             bard data to support their conviction that arrhythmia detection unit
             is feasible, valid and reliable detracted from a strong case:br the
             application.

             The personnel budget seemed reaso nable. The question  was  raised
             about the unusually high indirect costs for the Lockheed  Corporation,
             as well'as the 15% profit. The application was unclear as  to  whether
             funds are being requested for equipment already installed in Mt.  Zion
             Hospital.

             The Committee believed that evaluation pl-an based upon clinical
             experience at Mt. Zion would not necessarily be an appropriate analysis
             for small. hospitals. There were no comparison groups included in  the
             proposed analysis and the reviewers felt the extrapolation of experience
             at Mt. Zion for application to small hospitals would require peer
             review.


             The application was believed to be unapl)rovabl.e on technical grounds
             since the state of the art (24 hour'on-line monitoring) to date has
             not proven feasible and is -,til.1 in the re-search and development stage.







             California RNP                 2                      RM 00019  7/70.1.  &  .2



             Recommendation: Non-approval II     Revision to be   referred to a panel
                              of experts for technical review.

             Project #60 - Medical Information Services - Area     VI

             Critique: The  Review  Committee  recalled  that.a  request  for  this
                         project was submitted with the first operational proposal
             from this region,  and  its  subsequent  disapproval,  The  area  has
             persisted in its  desire  to  strengthen  its  medical  information  resources
             by bringing  information  directly  to  individual  practitioners  in
             the four-county Area VI, based at Loma Linda.

             The reviewers noted its obvious importance to the Area and the
             excellent cooperative efforts of the Area VI office and committees
             to link all the major medical  libraries  with  each  other  and  with
             hospitals throughout the  region.  It  will  afford  the  Loma  Linda
             facility with easy access to the larger library at UCLA.

             The representative of the  National  Library  of  Medicine,  who  also
             served as a consultant for this project, was present at the Review
             Committee meeting and was  able  to  clarify  this  project's  relationship
             to other similar programs in this  Area.  He  did  not  feel  that  a
             reduction,in funds would damage the project.

             Recommendation: Approval I - In a reduced amount.

                              01 Year:  $30,000          02 Year:  $40,000      03 Year: $40,000

             Project   #61  Intergraded Assistants Program - Area III

             Critique:  The reviewers concurred with the comments of the Continuing
                         Education and Training  Panel  that  proposed  training  course
             -appears to be overly ambitious.  The curriculum content was thought to
             be unfeasible in that it includes  too  much  for  the  length  o  training
             proposed. They cited  page  232,  item  I,  "Techniques  of  centrifugation
             including the use'of refrigerated ultracentrifuge", as an apparent
             inconsistency with nationally established one year post high school
             programs  for  Certified  Laboratory  Assistants.  Also,'there  is  no
             indication from radiologists or the State Medical Society that they
             endorse this program or would employ  this  level  of  trainee.  It  was  a
             point of question as to whether  trainees  could  be  employed  outside  of
             Stanford,in view of the rigid California licensing laws for laboratory
             personnel.

             The request for such  training  was  believed  to  be  relatively  expensive--
             approximately  $8,200  per  full-time  student.  The  proposal  will  probably
             add some personnel to the manpower pool at Stanford, but its overall
             contribution to patient care in the region was questioned.





             California RMP                   3                      RM 00019     7/70.1 & .2


             Phase III of the program was difficult to assess in view of the unaccept-
             ability of the Phase II portion above.  The reviewers felt that
             the curriculum emphasizes the laboratory too much and not enough on
             general internal medicine. Alg-d@--@ttLe responsibilities of the  physicians
             Iassistants are not spelled out.  The relationships to existing health
             personnel are not stated. The applicant  makes  no  reference  to  other
             similar programs under development in the country.

             Generally, this project was believed to be very poorly thought out.
             The training aspects ate quite unclear, the  licensure  problem  is  not
             dealt with, and it-would appear that the  region  has  not  investigated
             existing programs (such as Duke 'University) for preparation of this
             program.

             Recommendation:  Non-Approval I

             Project #56 - Community Resources and Information Services (CRIS) - Area VIII

                         The Review Committee acknowledged the review of this project
                         by a staff member of Comprehensive Health  Services,  who  has
             provided consultation to a majority  of  fifteen  existing  programs  throughout
             the U.S., funded under Community Health Service contracts.

             One of the original concerns of the Review Committee was the -relationship
             of this project to one previously reviewed and  funded  by  the  NCRD  (CHAIRS).
             The basic objective of both projects is the same:  to establish a
             Central   Info rmation and Referral  Service.  The  methodologies  are  different.
             The CHAIRS project is concerned with the application of computer
             technology to the process of referral, whereas the CRIS proposal    will
             employ standard accepted and proven techniques  in  developing  a  new  service.
             CHAIRS is a research and development activity, and  the  CRIS  project  is
             a seed activity for an essential component  of  a  comprehensive  health
             program in one of the fastest growing counties  in  the  U.S.  The  county
             has, and will continue to have, limited resources  which  must  be  utilized
             to  fullest  e'ffectiveness. The number and  variety  of  agencies  involved
             in the planning for this program is not only com'iuendable  but  unique.

             The pro5<lmity of the two programs in continguous areas was believed to be
             a benefit which will enable  personnel  to  utilize  mutually  beneficial  basic
             information.  It was noted that the provision of the listing alone will
             save six months time for CRIS, and will enable  project  staff  to  pursue
             new agency information. More important,  the  Los  Angeles  program  has
             evaluated the information, a process which usually  takes  about  two  years
             to   complete.

             The strength of the CRIS proposal is its creation under PIIP auspices,
             which assures the provision of professional and medical talent.  The known
             commitment of community agencies and the  university  medical  center  augur
             well for its future.






             California RMP                 4                     RM 00019  7/70.1 & .2



             The major weakness of CRIS was believed to be the  proposed  staffing.
             The suggestion was made that more time of the project  director  should
             be devoted to building firm working relationships with  the  community
             agencies and medical profession.   The second position  should  probably
             be filled  by someone with experience in community  organization  rather
             than in  case work. The emphasis of staff should be  on  developing  the
             service;  the cooperating agencies should provide individual  case  work.

             Such  central information And referral services have no other source
             of funds  for their development. Experience with  the  fifteen  contract
             projects  has been that all have been maintained through community
             resources after three years of initial  support.  The  principal  source
             for maintenance is from United Community funds, which will  only  give
             support after the service has been tested and proved effective.

             There was consensus on the basis of such a technical review,  that  this
             project fills a real need for an area with no existing hub for such
             services, and where all social services are fragmented  an  unorganized.
             The project has good self-supporting potential after three  years  and
             will obviously close existing gaps in improvement of health care..

             Recommendation:  Approval I

                              01 Year: $77,307      02 Year- $77,248     03 Year:  81,393



                                       SUMMARY  OF RF@,CO@iENDXEIONS


                                01 Year             02 Year            03 Year

               41                 -0-                -0-                -0-
               60              $30,000             $40,000            $40,000
               61                 -0-                -0-                -0-
               56              $77,307             $77,248            $81,393

             TOTAL            $107$307            $117,248           $121,393



             Dr. Gerald Besson and Dr. Mitchell Spellman were not present during the
             deliberation of this region.
                                                                         RMPS/GPIB
                                                                         7/16/70




















            a                                                              a                                                              0






                             REGIONAL  MEDICAL  PROGRAMS   SERVICE
                 SUMMARY OF  AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION
                                  (A Privileged Communication)




            CENTRAL NEW YORK REGIONAL                            RM 00050 7/70.1
             MEDICAL   PROGRAM                                   June 1970 Review Committee
            State   University of  New  York
            750 East  Adams  Street
            Syracuse, New York  13210

            Program Coordinator:  Richard H. Lyons, M.D.

            Requested,
                ram
            Period                lst Year     2nd Year      3rd Year    Total

            Direct Costs:         $48,649      $60,643       $64,658     $173,950
            Indirect Costs:       $15,328      $16,860       $18,546     $   50,734


              TOTAL               $63,977      $77,503       $83,204     $224,684


            Background: The Central New York   Regional Medical Program consists of
                         fifteen counties in Central New York State and two counties
            in Northern Pennsylvania.  The Regional Advisory Group is fairly repre-
            sentative of the medical needs  and  interests  of  the  Region.  It  has
            been recently reorganizdd;16 new members, largely consumers, have been
            added to give each  county  representation.  It  is  assisted  by  four
            standing committees in  heart  disease,  cancer,  stroke  and  continuing
            education, formed from RAG members  and  experts  from  the  Region  in
            these four areas. Altogether,  the  RAG  has  eight  committees  to  deal
            with problems such as  health  manpower,  hospital  needs  and  community
            health  education.


            The Central New York  Regional  Medical  Program'began  its  planning  in
            January 1967, with a  grant  of  $289,522.  The  operational  phase  of
            the program began in July 1968, with four projects.  Since that
            time eight additional projects have been approved, five of which
            have been funded. The  Region  was  awarded  $1,069,762  (d.c.o.)  for  a
            15-month period of which $462,500 (d.c.o.) is for core activities.
            The Region's funded projects are:
                                                                         DIRECT COSTS
            PROJECT                                                      15 MONTHS

            #1 - Continuing Education  in  Nursing  (02  Year)           $201,800
            #2 - Mobile Stroke Rehabilitation Service (02 Year)             183,092
            #3 - Oneida County Tumor Conference (02 Year)                     7,118
            #4 - Family Practice Program at St. Joseph's Hospital            43,827
                 (02 Year)
            #5 - Nursing CCU Training Program (02 Year)                      18,348
            #8 - Sigmoidoscopy  Demonstration   Training   Program           41,205
                 (01 Year)



              Central New York RMP             -2-                  RM 00050  7/70.1


              #9  - Medical Briefs by Telephone, Sayre, Pennsylvania              21,223
             #11  - Regional Learning Resources Center for Nursing                90,649
                    Continuing Educatfion (01 Year)
             #14  - Continuing Medical Education in Rural Pennsylvania
                    and New York (no additional funds)

             Those  approved projects which have not yet been funded are:
              #6  - Home Dialysis Training                                        Unfunded
             #10  - Community Hospital Equipment Request                          Unfunded
             #12  - Prevention of and Effective Recovery   from
                    Cardiovascular Illnesses Through Knowledgeable
                    Nursing Intervention                                          Unfunded

             A site visit was made to this Region in January 1969.  The reviewers
             recommended that the University  Medical  Center  (U.M.C.)  give  priority
             to the recruitment of physicians for core  staff  (there  are  none  other
             than the coordinator).  The U.M.C. stated that until vacant departmental
             head positions are filled it will  be  difficult  to  interest  physicians
             in faculty appointments.  Once  the  vacant  departmental  head  positions
             at the Center are filled, top priority will be given to filling the
             Regional Medical Program positions.
             The CNYRNP has organized a liaison faculty of board certified surgeons
             or internists who work in their local areas to coordinate Regional Medical
             Program activities with  community  needs.  Some  of  these  liaison  personnel
             have been successful in serving  as  local  regional  stimulators  for
             development of training and continuing education programs.  Mainly
             through the efforts of an active Nurse  Coordinator  on  the  core  staff,
             nurses throughout the Region have been  involved  in  a  number  of  continuing
             education projects for nurses.

             Present Application
             This supplemental grant  application  is  requesting  $173,950  (d.c.o.)  for
             three years support of Project #15 - Medical Library and Information
             Service.
                                                                                   Requested
             Project #15 - Medical Library and Information Service               First Year
                            This project sponsored by the Upstate                  $48,649
             Medical Center Library proposes to establish an adequate inter-
             library loan system and to provide the Region's librarians and other persons
             responsible for library services  the  training  and  consultation  they  need.
             Omitting the Upstate Medical Center Library, there are only 8 full-time pro-
             fessional librarians employed by hospitals in the region.  Four of
             these librarians are employed by  hospitals  within  the  city  of  Syracuse.
             Training programs are needed at a non-professional level for personnel
             presently employed in hospital libraries.
             The New York Academy of Medicine  Library  serves  as  the  Regional  Medical
             Library for New York and Northern New Jersey.  It serves in a "backstopping"
             capacity only and has imposed limitations on the interlibrary loan
             service.  These restrictions virtually exclude all libraries in the Central





            Central New York                       :3           RM 00050  7/70.1


            New York Regional Medical Program from access to the Academy Library
            except by referral.  The Upstate Medical Center Library has been asked
            to serve as a referral library for this region.
            The Upstate Medical Center Library proposes to meet the Region's need
            for library service by:  (1) encouraging and assisting in the development
            and improvement of local library facilities; (2) providing training
            programs for health personnel on the effective use of medical library
            and information systems; (3) supplementing local library resources
            by providing an efficient interlibrary loan service; (4) providing
            literature searches and reference service to health professionals
            in the area; (5) providing a current awareness service to keep members
            of the health profession informed about new developments in their field;
            and,(6) providing reference service for all forms of information needed
            to support continuing education programs including audiovisual teaching
            aids.
            To carry out the proposed activities the applicant has requested support
            of a Project Director (10%), two Medical Librarians (100%) and a clerical
            position (100%).
            For evaluation the program proposes to maintain statistical records
            on the use of each service, utilize the reports of the consultant librarian
            and do a mail survey with those persons who have used the services offered.
            As potential-future support the applicant identifies the health pro-
            fessionals (practitioners), the hospitals, and other health agencies
            (voluntary, county, medical societies, etc.).
            Second Year:  $60,643                      Third Year:  $64,658







                                                           DRMP 4/30/70





                                                                        A Privileged Communication




                                    SUi@2,iARY OF REVIEW AND CONCLUSION OF
                                         JUNE 1970 REVIEW COMMITTEE


                                 CENTRAL NEW YORK REGIONAL MEDICAL PROGRAM
                                             RM 00050 7/70.1

                            FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


              General:  Committee  concluded  that  this  application   which   requests   $173,950
                         (d.c.o.) for  a  three-year  program  period  be  approved  with  con-
              ditions at  a  reduced  level  of  $143,000  for  three  years  support,of  Project
              #15 - Medical Library and Information Service.


              Project #15 - Medical Library and Information Service

                    ue:  Committee  concurrs  with  the  comments  of.ttie  reviewers  from   the
                          National. Library of Medicine that this is a well thought out
              project which attempts through a series of interrelated activities to improve
              the  informational  services  available  to  health  workers  in  the  Central  New
              York Region.  The  project  as  developed  would  appear  to  cover,  in  a  balanced
              way, most of the needs of a region for information services

              Committee believes that this project has been developed as a result of
              increased demands being placed on the SUNY-Upstate library  ue to .1i.1
              activities out in  the  field  pointing  out  to  health  professionals  t  e  i-
              brary resources avail-able to them.  Committee believes the goals and        objec--
              tives of the  prooram  are  commendable  and  that  the  applicant  is  capable  of
              carryi.n@ it out. Hov?ever, there  is  in  the  application  a  certain  lack  of
              specificity relative  to  how  they  are  going  to  iniplement'tlieir  goals.  For
              example, under goal 3, out  of  five  suggested  implementation  steps  the  @qo,@@Os
              flivill explore the possibility" are  used  in  three  and  "it  is  anticipated"  is
              ;used in one.   ConirnittOe is also unsure of Mrs. Suzan.,i.e @furray's status  it,
              this program and would  like  clarification  on  whether  she  will,  be  utilize
              and paid as a full-time  staff  member  of  this  project,  or  will  she  remain
              on salary as a core staff member.

              Committee  believes  the  requested  budget  is-to  high,  particularly  the   office
              furniture  and  travel  categories  and  recommends  a,reductioti  in  the  budget.

              'Re,@ommendati.on:  Approva). I - at a reduced level. with the following condi-
                                 tiotis: (a) That  the  Region  render  clarification  on  how  the
              stated goal s  ire,to  be  implemented;  (b)  clarification  on  bow  the  services
              of Mrs. Suzanne Murray    are to be supported.

              First Year                        Second Year                      Third Ye,@,,r
                @lto,ooo                          @50,000                         $53,000





             Clz,NTRAL NEW YOIU( RIIP                   -2-                 KI 00050 7/70.1




                                   COIOII'J'TEE FUNDING RECO14MENDAI'IONS (D.C.O.)


             Lr-OjL C t-         Year---           Requested            Recommended
             #15                  01               $48,649                $40,000

                                  02                60,643                 50,000

                                  03                64,658                 53,000


                   Total                          $173,000.              $143,000














                                                              RMPS/GRB/7/8/70


















































































                                                                                                                                               i
            0                                                              0                                                              o@ @












                                    REGIONAL MEDICAL PROGRAM SERVICES
                       SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                      (A Privileged Communication)



               Colorado-Wyoming Regional Medical Program                   RM  00040   7/70.1
               University of Colorado Medical Center                       June 1970 Review CoiTmittee
               4200 East Ninth Avenue
               Denver, Colorado  80220

               PRO(,'RAM COORDINATOR:  Paul R. Hildebrand, M. D.

               ILc,quested        Ist   Year        2nd   Year       3rd   Year         Total -

               Direct Costs         $108,177          $123,024         $132,297         $363,498
               Indirect Costs         18,185            22,399           24,231          64,815


               TOT@,               $126,@362         $1.45,423         $156,528         $428,313

               IIT.ST@)RY:  This  Region's  planning  grant  period  was  for  two  years,
                          January  1,  1967  -  December  31,  1968.  A  total  of   $361,984
               was  awarded  during  the  first  year  and  $366,723  during  the  second  year.
               Also,  during  the  second  year  of  planning  an  earmarked  project   in
               pediatric  pulmonary  disease  was  approved  for  three  years   and   funded
               at  $49,615  the  first  year  (six  months).  Following  a   September   1968
               site visit and  at  the  end  of  the  second  year  of  planning,  the  Region's
               initial operational application was approved for three years
               ,January 1, 1969 - December 31, 1971.  The first year operation award
               was $1,003,902 (total- cost), for the support of core staff ($481,976
               d.c.),  six  new  projects  ($308,997  d.c.),  and  the  second  year  of  the
               pediatric  pulmonary  disease  project  ($58,080   d.c.).   In   February   1969,
               Council approved two of four projects submitted in a supplemental
               application  which  resulted  in  an  award  of  $142,922   (total   cost).

               Five  new  projects  were  considered  during  the  August  1969  and   December
               1969  Review  Cycles.  All  were  approved,  at  the  combined   level   of
               $117,505  (d.c.).  A  supplement  application   consisting   of   two   projects
               was  reviewed  during  the  March  1970  Review  Cycle  resulting  in   the
               approval of one project and non-approv@i.1 of the other.

               In December 1969, Staff reviewed the Region's 02 year Continuation
               Application which requested $1,229,192 (d.c.) for support of Core
               and ten on-going operational projects.  It was Staff's observation
               that  most  of  the  projects  were  moving  along  very  much  as  anticipated.
               However,  three  projects,  #3  -  Multi-Media   Education,   #4
               Tra@l.nin,- System and  #13  -  Pediatric  Pulmonary  Center,  were  cited  as






           Colorado/Wyoming RNP           -2-                 RM 00040 7/70.1

           exceptions.  These projects shared the same basic weaknesses; they
           did not relate to the original objectives, they were vague, their
           evaluation design and techniques were poor, and they failed to
           coordinate with, and relate @o, other projects. As a result  of  the
           review, the Region was awarded its 02 year committed level  of
           $1,108,113 (d.c.), and was requested to submit revised budgets.
           In addition, it was also requested to submit revised  progress
           reports on the three project's which received critical reviews, and
           new proposals for use of unexpended funds.
           In May 1970 Staff reviewed the revised progress reports, revised
           budgets, and new proposals for use of unexpended funds which were
           --equested from the Region as a part of the action taken on the
           Continuation Application reviewed by Staff in December 1969.
           Staff found the revised progress reports on projects #3 - Multi-
           Media Education, #4 - Home Dialysis Training and #13 - Pediatric
           Pulm2nary Center, to a large degree failed to relate to the
           specific questions posed to the Region in the  advice  letter.
           Many questions were not spoken to, while others were answered in
           the same vague generalizations which characterized the original
           progress reports. In many instances the educational  programs  being
           conducted appeared to be Lmstructured and absent of  good  educational
           design. It was noted evaluation is obviously  lacking  and  apparently
           no assistance in this area is being provided by Core Staff or  other
           qualified personnel.
           Staff found the revised budgets for use of 02 year  committed  support
           to be appropriate with exception of two projects.  Project #13 -
           Pediatric Pulmonary Center, requested additional support for the  02
           year which staff felt was not justified by the poor  progress  report.
           Project #15 - Pediatric Oncol           requested support  of  Fellows
           previously de led by Committee.
           Of the 15 proposals submitted for use of $98,776 01 year  unexpended
           funds, ten representing $73,217 were recommended for approval.
           See the attached chart for funding status resulting from  the  revised
           project budgets and the request for balances.  A list of unfunded
           projects is attached, also.
           As A result of the recent release of funds by the Bureau of the
           Budget, a special supplement is pending which would increase the
           level of funding for Projects #14, 15, 18 and 19 by  $100,000.
           PRESENT APPLICATION:  This application consists of one project,
                                  #13 (R) - Diagnosis and Treatment of  Pediatric
           Pulmonary Problems, which is requesting renewed support for three
                             ' inally an earmarked project funde
           years.  It was orig                                  d as a part of
           Core at $43,879 (d. c.),for the period July 1, 1968 - December 31,
           1968.  Included in the award was a commitment of support of two
           additional years.  As a result of the Region going operational on






            Colorado/Wyoming                   -3-           RM 00040  7/70.1

            January 1, 1969, the project was withdrawn from  Core,  given  autonomy
            as Project #13 and was awarded $58,080 (d.c.) for  the  01  operational
            year. January 1, 1969 - December 31, 1969.

            During the latter part of 1969 the Region submitted its non-
            competing continuation application for Core and  eight  operational
            projects, of which Project #13 was one.  Staff review of this
            particular project was quite negative. They  found  the  progress
            reports to be very sketchy and difficult to relate to  the  original
            objectives which were: to conduct 10  specific  postgraduate  work-
            shops throughout the Region, conduct speaking engagements  and  brief
            demonstrations, develop teaching aids for ensuing programs  and  make
            administrative arrangements for future  workshops.  The  applicant's
            use of broad general terms, such as visits, meetings and  trips  to
            describe activities of the program over the past  year,  provided
            little insight into actual accomplishments.  It  was  noted  evaluation
            is neither process or product oriented.

            As a result of the staff review, the Region was requested  to  submit
            within 120 days, a revised progress report answering specific
            questions related to staffs' observations.
            The Region has responded with a revised progress  report,  included
            in this application, which Staff has identified as more of  the  same
            ambiguities, failing to answer specific questions conveyed  to  the
            Region in the advice letter. Staff has  subsequently  recommended  to
            the. Director PdfPS, that this project be allowed new funds in the
            amount requested, $75,956, for the period January 1, 1970 - January 31,
            1970, but that the request for use of $13,256 of the  previous  years
            unexpended funds for this project be denied. It  is  requested  that
            the Staff of the Continuing Education and Training  Branch,  Division
            of Regional Medical Program Services, visit the Region as  soon  as
            possible to observe the project first-hand and offer  what  appears  to
            be badly needed assistance.
            Project #13 R - Di znosis and Treatment of Pediatric Pulmonaa         Rec ested
                                    IS al
                             Problems.  The basic goals of this project are       First Year
            to place in various areas of the RegionFellows trained in             $108,177
            pediatric chest disease and to further the training  of  existing
            practitioners, nurses and public health nurses in  the  diagnosis
            and treatment of these conditions.  These goals are to be
            approached, basically, by the following mechanisms:  1)  A  Fellow-
            ship Program whereby  two Fellows will be accepted each year for
            a program emphasizing pulmonary disease training and  not  research;
            2 and 3) Visiting Consultation - Teaching Clinics  for  Physicians:
            Visiting Consultation - Teaching Clinicis for Hospital  Nurses  and
            Technicians:  These two types of clinics, which ordinarily occur
            at the same time, will be conducted in 14 communities  of  5  different
            states; 4) Visiting Consultation Clinics for  Public  Health  Nurses
            and Visiting Nurses: These nurses will  have  the  opportunity  or  any
            needed instruction in any specific procedures or  treatments  needed
            by the home patient and will receive any assistance she  wishes  or








           Colorado/Wyoming RMP             -4-             RM 00040  7/70.1


           needs in evaluating the extent to which the patients are  following
           physician's instructions and maintaining environmental control;  5)
           Sliort-Term Postgraduate Programs: There will be conducted as  both
           a follow-up to and as a stimulant to participation in locally-
           conducted visiting clinics. Several postgraduate programs  will  be
           offered each year in cooperation with other RMP sponsored courses
           in Adult Pulmonary Disease and in  cardiovascular/cardiopulmonary
           disease; 6) University Preceptorship: will be offered to  at  least
           one interested community practitioner who would come to the medical
           center and work and study in Pediatric Intensive Care Ward.
           Depending upon the physician's particular needs, a formal  course of
           instruction and experience would be developed.

           No educational design or detailed curriculum is provided for  the
           individual programs.  The general course material which is outlined
           is essentially the same for all programs.  It will differ only in
           that it will be presented in greater or lesser depth and  breadth
           depending on previous levels of training.

           A progress report for the period July 1968 - January 15, 1970  is
           presented.

           Second Year:  $123,024                     Third  Year:  $132,297







              Colorado/Wyoming RIP                    -5-             RM  00040   7/70.1


                                   STATUS OF PROJECTS NOT FUNDED

              Project Number                     Approved
                 and Title                   Project Period                     Status
              #11  -Facilitation of                                         Not Approved for
                    itearning                                                 Funding
              #12  -Continuing Education                                    Not Approved for
                    Workshops                                                 Funding
              #16  -Comprehensive   Cardiac   Care   2                      Approved but
                                                                              Unfunded

              #17  -A Training Projzram for          2                      Approved but
                    The  Development   of   Ultrasonic                        Unfunded
                    Techniques in Community
                    Hospitals
              #19  -Chronic   Disease   Evaluation   3                      Approved but
                    and Management of Patient                                 Unfunded
                    Care

              #20  -Daily  Update  of   Laboratory                          Not approved for
                    Reports                                                   Funding





                                                COLOR,,%DO/WYO@IING REGIONAL MEDICKL PROGRAM
                                                              5-GQ3-RM-00032-02                                           -6-

                                              Revised Projec@                      for Balances
                                                  Requested                        Requested 01
        Project Title                        02 Year Committed          Staff     Yr.Unexpended     Staff           Total       Total Staff
                                                   Funds             Recommendati-n     Funds      RecommendLtion   Request     Recommendat:
         and Number                           -          -
    -  CORE            n of Health Data              $516,050        $516.050           $1 00      $1,000
       A.  Organizatio                                                                      645    Non-
       B.  Provision of Health Programs                                                    -      Non-App.
       C.  Production of Slide& Voice        es
       D.  Electrocard               a Phone                                            1,700
       E.                                                                               2,500       2.500
       F.                            g Aids                                             4,735     Non-App.
       G.                                                                               1,360       1.360
               TOTAL CORE                           $516 050                            $13,087    $6 560          $529,137      $522   610
     - CANCER REGISTRY                                                                  -0-           -0-
       HULTI-MEDIA EDUCATION                                               739          16.000      8,000
       HOME DIALYSIS TRAINING                                                           8   435      8,435(2)
                                                                           ,604         17,641     17,641
                              TRAINING                                                  -0-           -0-           58 2
                                                                                        2.555        2.555          25,294          25  294
       CONTINUING EDUCAT ON FOR NURSES                                     1912         -0-                         70,912          70  912
                            ON   STKFF                                                                              112,473            .687
                                CENTER                                                  13,256    Non-App.          89,212          75   56
   .4   STATISTICAL   DIA   OSIS   AND PROGNOSIS                                        9,364     Non-App.          22,681          13  317
   .5- PEDIATRIC ONCOLOGY CENTER                                               (i       30.326      30,326          51,300          44,701
   18- PATIENTS WITH ADVANCED CANCER                                                        -0-       -0-           10,000          10,000
              TOTAL                                          881     $1,076 282        $132,450    $7                           @l  149,
                                                     $1,08 881        'PLUS             $98,776  Actual           1,181,657
                                                     Committed                          01 year unexpended         Total
                                                 level available                           Funds               Available for
                                                  for request                                                       Request


                 (1)As recommended by Committee - No support for Fellows.
                 (2)Restricted pending Staff visit.





                                                              A Privileged  Coi-iiniunicaLi.on



                                     SUI,,U@@Y 01' REVIEkl AND CONICLUSIO14 OF
                                           JUNE 1970 ADVLSOI@Y COUNCIL

                                COLORADO/@v'YOI.IING RECIONAI, MEDICAL PROGRA@T
                                             @l 00040  7/70.1

                            FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL



                General:  The  Committee  decided   that   this   application   should   not   be
                            approved,  although  it  recognized  that   the   one   project   for
                            which  funding  was  requested   was   ongoing   and   represented
                the development of a valid regional referral resource.

                Project #13R - Di.      si-s and Treatment of Pediatric Pulmonary Problems.

                -Cri        Since  consideration  of  thi-s   application   occurred   early   in
                            .Its meeting, the Committee flagged two areas of interrelated
                            concern   which   prevailed   throughout   the   Committee   meeting;
                support  of  clinical  training  for  fellows   and   support   for   regional
                referral centers.

                Co@-inittee noted the progress of this project which had been funded
                from  earmarked  funds  in  1968;  the  activities  to   date   have   stimulated
                referral  of  patients  and  physician  consultations  regarding  m@ina'gc@iiicrLt
                of  the   patients.   These   were   considered   valuable   outcom-2s   althol-h
                the  Committee  recognized  that  these  accomplishments   niiEbt   not   be   an
                appropriate  outcome  of  D@T  funding.   Funding   for   felloi,,,sbip   training
                (whether  it  is  advanced  medical-  residency  training  was  not   clear)   was
                requested,  and  the  Committee  felt  this  was  a  valuable  idd.iti.on   to
                Ro-gi-onal resources even though it may not be -,-i appropriate use of Pl,a'
                funds.


                The Coma-!iittee noted that the incidence of pulmonary disease in pecli,--@-t.3-ic
                patients is hiQh.

                The reviewers observed, however, that!-.         qualities  of  the   activity   -
                continuing  education  for  all  referrin.',@  physicians  and  all-ie(l.  health
                personnel, development of peripheral centers, c,,tc, - were inadequately
                described both in the report of proor(.,-@o, to dit,2. -@irid ill the project plans.
                The activity, in fact, seems unrelated to other r,tT efforts in continuing
                education for hospital personnel.        The  l@TIP  core  itaff  i-n  continuing
                education apparently is no,- involved.        ]'he  T)rojc2ct's  inclusion  in  a
                Regi.c)r,al M@di-cal PiL-c)i@-i-aiii incid(--@i-ta'

                The ConliRi-tt(@e was  concerns(!  ql)out-  the  separateness  Of  this  activity
                winner      p@, end felt it                                  otli(-@i.- R@T efforts-.





            -COIIORADO/loJYO'@IIEIG               -2-            @l 00OZiO  7/70.1


             Recomme,iidation:  I\Ion--Approval- 11 - Return for revision with clarifica-
                               tion of the following:

                   1.  The relationship of tlii-,s,,project to Project 10 - Colitinu'
                       Education. Staff and Projcc'@'-#6...- ResT.)iratory Care.

                   2.  Hov7 will the project continue after the grant period and
                       what other sources of support have been explored? Particularly,
                       have the sources of support for Fellows been investigated?
                       If so, what are they?

                   3.  Details of proposed educational activities.

                   4.  What is the academic level of the Fellows being trained? Are
                       they residents?

                   5.  Is income being generated and if so, is it being applied against
                       the grant?




































                                                        D R@,ql G R?j
                                                         7/15/70

















             a                                                              0                                                              0









                                      REGIOINA.L tIEL)!76,AL PROGRAMS SEJTVICE
                           SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                             (A Privileged Communication)


             Florida Regional Medical. Program                             RM   00024    7/70.1
             1 D@ivi,@; Boulevard, Suit(, '309                             June 1970 Review Committee
             Tampa, Fl.orida   33606

             Program Coordinator:  Granville W. L@irii-nore, M.D.

             R(-(-Iiies t ed            lst  Year        2rid Year        3rd Year            TO'I'A 1,
                                       $1  44,690        $95,588          $98,288            $3'38,566



             'I'O'I'Al,                  $144,690        $95,588          $98,288            $338,5()6

                            The Region recei.ved its fi.rst planning funds on November 1,
                            1967  after  submitting  three  applications   (an   original   and
             two revisions).  Almost at the same time the Region received its planning
             continuation  award,  which  included  an  earmarked  hypertension   stu   y,   it
             submitted its operational application and four supplemental plannin@,,
             applications.  In February 1969, Council approved operational status for
             the Region and nine operational projects and three of the planning
             supplements.  The level of support for core, $682,000, now includes funds
             for  the  coordinator's  office  in  Tampa  and  for  subregional  programs   in   North,
             South  and  Mid-Florida.  The  current  level  of  funding  for  core   and   nine
             project,, is  @l.,471,000  .  The  Fl.c)rida  RMP  is  presently  organized  into
             three  areas  for  ease  of   program   management   and   administration.   Coordinating
             tlie.@,i(-,ti.vi.ties of the three area offices is a state office based in Tampa.
             The state office provides statistical, grants development and management,
             and public relations services for tlic@ Region.       The  three   area   offices
             li.ivc- been staffed to varying degrees, the North Area offi.ce being the most
             -active  in  stimulating   projects.

             The  applicant  agency  is  the  Florida  Regional  Medical  Program,  Inc.,  which  is   a
             nonprofit  corporation   established   by   eleven   organizations   with   representatives
             from  the  University  of  Florida  College  of  Medicine,  University  of   Miami   School
             of  Medicine,  University  of  South  Florida,   Florida   Heart   Association,   Florida
             Florida  Hospital  Association,  Florida  Cancer   Society,   Florida   Board   of
             Regents,  University  of  Miami  Board  of  Trustees,  Florida  Board  of   Health,   the
             Florid@i Medical Association and the general public.  The 31 member Regional
             Advisory  Croup  makes  the  fi-nal  determinations  on  projects,  but  the  FRMP,   Inc.,
             maintains a large degree of administrative control, as well as elects the members
             of ttic,. Regi-onaL Advisory Group.  The Region has also established some Task
             Forces in categorical. and functional areas.




                  Regional          Program          -2 -                    RM 00024   7/70.1
           i)rt)@,,r;tni sit(, visi-t- was licLd in Jantiiry 1970. The. site team which visited
          Cli(, l@(.,@-,,ion rcl)ortc@d on a number of problems seriously liaTTiperiiip, the RMP'.,,,
          O[)c,r,iLion.      problems related Lo the l@egional Advisory (;rotip--ttie need
          for @i more representative, including minority group  membership, the need
          for effective working committees and the need to wrest control of the
          program from the applicant agency; the seccesionist moves on the part of
          the North Florida Area and the program imbalance among three FRMP areas.
          The February Review Committee and March Council heard and approved the site
          visitors' recoimDendations relating to these problems.     Specifically, they
          urged that secessionist moves be discouraged and that Florida remain a
          single Region.   To this end, national reviewers were advised to give priority
          to programs in Southern and Central Florida to help redress the imbalance
          among the three areas.    The reviewers also indicated that representation
          on the RAG should be broadened  and  that  the  actions  of  the  applicant
          organization be monitored to  insure  that  the  legal  authorities  and  responsi-
          bilities of the RAG not be abrogated by FRMP, Inc.      Finally,  the   development
          and review of projects, which have suffered a high disapproval rate during
          the past year, should be  improved  by  strengthening  core  staff  at  the
          assistant level, the Task Forces and the RAG.
          As a result of the site visit, the Region  has  begun  to  resolve  some  of  their
          prol) I cnis .The Regional Advisory  Group  has  added  three  new  members,  bringing
          t'.-ie total minority representation to three and is taking  a  more  active  stand
          In its relations with the FRMP, Inc.     The IOIP is reorganizing its subregional
          offices so that instead of three area offices and various sub-area offices,
          responsible to the area offices, there will be nine district and three
          medical school  offices,  all  directly  responsible  to  the  Coordinator. Each
          of these offices will be staffed by a physician who the Region feels should
          have as one of their main responsibilities that of liaison between FPDIP and
          the medical society.


          Pres
                                                                                       Re(itiested
          :"--oject #36 - A Hospital-Based Program for Cardiopi-tlmoiiar       usci@   First Year
                         tation in the State of Florida.     The  Florida  Heart        $144,690
          Associati(-)ii will sponsor this proposal to  establish  a  continuous
          training program in cardiopulmonary resuscitation in Florida.        A
          program to accomplish this cyeneral. aim has been developed with the
          following specific objectives:     1) train  and  retrain  key  physicians
          and registered nurses who will assume responsibility for training
          (@tlier hospital personnel in CPR; 2) encourage and assist hospitals in
          establishing  emergency  resuscitation  measures;  3)  establish   uniform
          standardsof training  for  hospital  personnel  according  to  the  recom-
          niendations of the National  Research  Council;  4)  provide  training  for
          future instructors in CPR at the community hospital and through a
          decentralized delivery system.     The American Heart Association
          t'lirric@ulm and standards wi.11 be followed throughout  the  project.
          Of the 197 hospitals in the state, the proposers estimate that 127
          W()tild need teaching proprams.   The remaining 70 including larce
          institutions, Such as mental liospitals,would be spotcheci@ed.     A




                  (I;i IZe@, i ()na t M(,d I Program   -3 -                    l@   000247  70. 1

                                 f@iciliti,(-,s wi.11 be carried out           tailor
             @;ttrvc-y @)f- hospital                              in order L(
             the CPR program to  the, individual hospital.   The state  would  be
             divided into four geographical areas for ease of management.  Each
             area will be staffed try a full-time CPR Coordinator, who will
             conduct or assist in CPR training at the hospital level.

             Each faculty coordinator will receive  four  weeks  of  training  at
             either the University of Florida or the University of Miami.  The
             other trainin@, personnel mentioned in the proposal  are  CPR  faculty  and
             instructors, but the relationship among the three and the specific
             training responsibilities for each are not well defined in the
             proposal.  The training design is marked by a similar lack of clear
             (I ef in j- Lion.

             (,PR faculty wi-li train instructors who will  devise  schedules  for
             @iiid offer training to physicians, nurses and other  al.lied  health
             personnel at institutions  in  their  respective  areas.  Class  size
             is limited to 15 people, but the project does not specify how
             many courses will be held  during  the  three-year  project  period.
             The number of classes conducted, students trained and student
             proficiency in an AHA examination will be studied.
             t4lien there appears to be no activity following initial CPR training
             (,a Leisure of the percentage of persons  trained  compared  to  the
             total number to be trained), another effort  will  be  made  with  a
             different person designated as  the  responsible  authority  in  the
             same. hospital. Ultimately, the  proposers  expect  that  more  than
             75% of the eligible personnel at each hospital will have been
             trained.  "Random visitations" of courses by senior faculty
             personnel as the courses are being given wi.11 be another subjective
             measurement of success. Forms leave,  been  developed  for  personnel
             Lo record results of each CPR episode in the hospitals.
             The Florida lic,art Association has been conducting a CPR pilot study
             ,,i.licc, September 1969.  This pilot
                                                 study has shown that "it is
             necessary to have all equipment  transported  to  the  training  site
             rather than relying upon availability of specialized apparatus at
             the location." Accordingly  a  standard  panel  truck  is  being  requested
             for each of the area coordinators to  haul  the  training  aids  from
             hospital to hospital.  The amount of $11,630 in equipment for each
             area includes $3,000 for the van  and  $8,630  in  teaching  equipment  and
             material. Additional funds  for  two  teaching  trainers  at  $10,000  each
             and for closed circuit TV at $3,500 round out the remainder of the
             ,s58,390 total equipment item in the budget.
             $54,000 Ln personnel is also requested for the state coordinator, three
             area coordinators and a secretary.  The coordinators are expected to
             have a I)achelor's degree in health education or health related fields.
             A cadre of pliysici@ins and nurses available as consultant-, are li.sted
             with the proposals.
             S(,cotid Yc,ar:  $95,588                    ']'Iiird Year:  $1)8,288


                                                                                 (;RB-5/12/70





                                                                      A PKIVILI,@ull@D uui@]iviu   NIUA.II VIN


                                                                            FLORIDA @IP  00024- 7/70.1
                                                                                O.


              STAFF OBSERVATIONS


              History of Review Actions of Operational Projects

                                                                            (Direct Costs)
                                                                              02 Award
              N Y@l  - Community Multitest Health
                          Screening    Center                                @179,150
              N  #2  - CCU for North Florida                                    24,727
              N  #3  - Regional Computerized EKG
                          Processing Center                                     1141566
              N  #4  - Cardiovascular Laboratory
                          Training    Program                                Disapproved
              N  f5  -   Postgraduate   Intensive   Inservice
                          Education for Physicians                              67,148
              N l@6  - Continuing Medical Education
                          via Open Circuit TV                                Deferred
              N Yi-7 - Training of Pulmonary Function
                          Inhalation   Therapy    Technicians                Withdrawia
              N #8   - Computerization of CCU's                                 39,706
              N #9   - Diabetes Proposal                                     Disapproved
              F #10  - Cardiovascular Screening       Program in
                          Four Rural Counties                                   95,631
              F #11  - Stroke   Survey   and   Rehabilitation                Returned'for     Revision
              F #12  - Computerized EKG Screening Program                       35,400
              S #13  - Stroke Professional Education Program                 Deferred
              S #14  - Pediatric Pulmonary Disease Center                    Deferred
              S Y@15 - Supervision of Paramedical. Personnel.
                          via Telemetry                                         37,443
              S #16  - Coronary Care Nurse Training Prooram                    .112,917
              S #17  - Consulting Conferences in Clinical
                          Cardiovascular Disease                             Returned   for   Revision
              N #18  - A Computer Program for Blood
                          Banking                                            Disipproved
              F #19  - Smoking   and   Health                                Returned   for   Revision
              F #20  - Florida    C'ancer Control Program                    Disapproved
              S #21  - South Florida Regional Cancer
                          Program                                            Returned   for   Revision
              N #22  - Pediatric Continuing Education                        Approved   but   Unfunded
              N #23  - Continuing Education - the Community
                          Hospital Level                                     Returned   for   Revision
              N #24  - Demonstration Project in Patient Care
                          Continuing Medical Education (Pensacola)           Returned for  '  Revision
              N #25  - Regional Streptococcal Disease Laboratory             Disapproved
              M #26  - Cardiovascular Laboratory -
                          Mid-Florida    Area                                Disapproved
              N Y@2.7- Cardiovascular Laboratory -
                          North Florida Area                                 Disapproved
              F #28  - Smoking   and   Health                                Approved but not Funded
              F #29  - Pediatric Pulmonary Care Unit                         Returned   for   Revision








              STAFF OBSERVATIONS                        -2-                   'FLORID-,@ @IP


              M #30 - Program for Prevention and Rehabilitation of
                         Cerebrovascular Disease                            Returned   for   Revision
              N Y@31 - South East Regional Selk-@earning
                         Program for Skeletal Patho',I.og_y                 Disapproved
              F IP32 - Demonstration - Cardiovascular  "
                         Screening Program                                  Returned   for   Revision
              F IP33 - A Regional Program for the Diagnosis and                                      1
                         Treatment of Cancer in Children          -         Approved   but   Unfunded
              S Y@34 - A Rehabilitation Program for South Florida           Returned   for   Revision
              M Y@35 - A Demonstration  of  Health  Guides  for   a
                         Model Neighborhood Area                            Approved  but    Unfunded
                            Project Sub Total                               $706,688
                            Hypertension Earrrark                               82,280
                                               TOTAL                        $788,968



                Funding Under Negotiation from the $5 million earmarked funds.




              N - denotes application submitted by North Florida area organization/insti.tutioii
              m                 It                   if         11
                -                                       Mid
              s                                      if
                -                                       South
              F -                                       Statewide







                                                               A Privileged  CcmTnunicatioii

                              SUMMARY OF REVIEW AND CONCLUSION OF
                                   JUNE 1970 REVIEW COMMITTEE

                                FLORIDA REGIONAL MEDICAL PROGRAM
                                         RM 00024  7/70.1

                      FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL

                                                                   I
               General: Review  Committee  recommended  returning  for  revision  this  one-
                         -project application which  requested  $338,566  for  a  three-year
               program period to support A. Hospital-Based Program for Cardiopulmonary
               Resuscitation in the State  of  Florida.  The  reviewers  recalled  from  the
               site visit in January the need for statewide, in addition to southern
               and mid-Florida-bas6d, projects  to  redress  the  imbalance  among  the  three
               Areas. Although this project  would  serve  all  hospitals  in  Florida,  re-
               vi-(,wers felt that the details wete-not  delineated  well  enough  to  warrant
               approval in its present form.  Committee  also  wondered  about  th.2  need  for
               this project in light of the health needs of the Reg on.


               Project #36 - A Hospital-Based Program for Cardi2.@-MO
                              in the State of Florida

                           The reviewers recognized that this project    has  local  support
                           and would use the American Heart Association Course for cardio-
               pulmonary resuscitation. However,  only  one  and  a  half  pages  of  narrative
               explain what will be done, how and  by  whom.  No  results  Of  the  pilot  pro-
               gram conducted by the  Heart  Association  are  given.  The  Continuing  Edu-
               cat-ion and Training Branch believed the  project  was  unclear  about  the  use
               of consultants and the evaluation of  the  teaching  capability  of  the  indi-,
               vidual to be trained in the course      (Evaluation  of  proficiency   consists
               solely of a test given on the completion of the one day of training.)
               The names of those people listed as associate investigators are highly
               qualified, but the reviewers were not  sure  just  how  involved  they  would
               be.
               Committee thought this  project  could  create  an  effective  learning  experi-
               ence if it attacked this as  a  problem  in  training  teachers,  but  reviewers
               doubted that this could be accomplished i.n the one-day training period
               described. The  Committee  also  doubted  that  any  other  organization  would
               want to assume the funding of the project T.@,iien RMP  support  is  terminated.
               If revised, the project should  give  more  information  on  the  pilot  study,
               the coordination of personnel, how consultants will be used, teaching
               methods, how trainees  are  selected  and  follow-tip.  Committee  also  retom-
               mended the project should be phased into development.

               Recommendation:  Return for revision.


                                                                      DPMP  7/2/70


















            0                                                              0                                                              0



        CEORGIA Regional Medical Program           -2-            Rm 00046  7/70.1
        Attached is a summary of the operational projects currently being supported
        by GRMP and status of unfunded projects.

        PRESENT APPLICATION
        Two (#31 & #32) of the three new projects that mak@  up  this@'applicatibn
        propose to assist in the establishment of area facilities concept  whi--h' is
        recognized, as high priority, in the accompanying task  Force  Reports
        Through the area facility concept, GRMP has sought to identify the strongest
        hospitals in each geographical area of the State and has assisted them in
        providing improved services in the general areas of: continuing education of
        all health professionals, improved diagnostic services,      development of case
        funding and development of case finding risk  factor  screening  community
        program.
        The remaining project #33, was also developed in accordance with Task Force
        recommendations as cited in the accompanying Task Force Reports.

                                                                             Requested
        Project #31 - Development of Cardiovascular Area Facilities.  The    First Year
                      goal of this project is to develop comprehensive        $179,496
        service components, consisting of prevention, diagnosis, treatment
        and rehabilitation on cardiovascular diseases in large hospitals
        designated as Area Cardiovascular Facilities.  Six unidentified
        facilities will be designated the first year with a total of 15 to
        20 in the project period. The specific objectives  are:  1)  to  develop
        a mechanism for the selection and development  of  "facilities"  based
        on a priority system, 2) provide for expansion of services in facili-
        ties which lead to comprehensive programs, 3) provide  flexibility  in
        the development of new services so that facilities may meet  the  most
        pressing needs of the area.  The first step in implementing the
        program will be to survey all hospitals of 200 beds or more  to  identi-
        fy all existing services. From this tabulation  the  Task  Force  will
        establish priorities, and hospitals high on the priority scale  will  be
        notified of elegibility to submit requests for designation as area
        facilities and for GRMP support for development or expansion of
        services. In order to receive support,  area  facilities  will  submit
        detailed short and long range plans and make recommendations for
        funding.  All facilities will be available to all patients regardless
        of their ability to pay. Other programs, cited  by  the  applicant  as
        relating directly" to this project,  include:  the  training  programs
        in coronary care, the study of  the  feas''bility of linking small hospitals
        to larger hospitals for patient monitoring and  consultation  and  the
        proposed demonstration in rehabilitation of  cardiovascular  patients.
        However, it is not specified how the programs  will  relate.  In  addition
        no mention is made of this project's relationship to project #8 -
        Improvement and Coordination of Facilities for Cardiovascular Diagnostic
        Services. The overall assessment of the project will  be  based  on  a
        determination of the statewide increase in services  for  cardiovascular
        patients and availability of these services to those  who  need  them.  In
        addition, assessment procedures are provided for each of the objectives.
        The first year budget request, which is based on the  development  of  six
        area facilities, is reduced in proportion to the 20%  time  delay  antici-
        pated in recruiting and implementing the project.
        Second Year:  $240,372                          Third  Year:  $257,974





       GEORGIA Regional Medical Program            -3-           Rm 00046  7/70.1

                                                                             Requested
   OProject @k32 - The Development of Stroke Area Faciliti@      Thi,,,      First Year
                    project is designed to compliment an existing  activity,  $189,576
       "A Comprehensivi? Statewide Stroke Program" by J'.mplementing area
       stroke facilities in various geographic areas of the state.  The
       specific objectives are: 1) to stimulate the development of six
       comprehensive area stroke facilities until services are available in
       all parts of the state; 2) to allow flexibility in development so each
       facility can build its own resources at the time and date feasible for
       its service area; and 3) to provide assistance to the area facilities
       such as training programs for personnel, resource materials for health
       education, and consultative services.  The first step will be to
       establish priorities for implementation of the primary area facilities.
       Primary consideration will be given to implementing area stroke programs
       in those facilities which already have personnel and @esources to pro-
       vi.de some services.  The second level of priorities will be given to
       those facilities which may not have a range of services already available,
       but which serve an area notably lacking in stroke services.  Each
       facility which meets priorities will develop a written plan based on its
       own resources, its estimate of community needs and what could be accom-
       plished with      help from GRMP.  The Task Forces of GRMP have estab-
       lished seven service area components which should be developed in each
       area facility and these components will be considered in establishing
       priorities for implementation.  Participating agencies in the planning
       and implementation of the area facilities will include the  Georgia
       Heart Association, the Georgia Division of Vocation  Rehabilitation
   *and CRMP.  Training programs for area facility staffs are being developed
       by GRMP, in cooperation with both schools of medicine, Georgia and Emory,
       and the State Department of Health. Evaluation procedures  will  be
       focused on determining the degree to which all residents have access to
       comprehensive stroke services.  The first year budget request, which is
       based on the development of six area facilities, is reduced in proportion
       to the 20% time delay anticipated in recruiting and implementing the
       project.
       Second Year:  $254,232                     Third Year:  $273,220

                                                                               Requested
       Project #33 - A Short-Term Preceptor Training Program to  Introduce     First Year
                     Medical Students to Medical Practice in Rural Georgia.     $7,800
       This project was prompted by the disparity of distribution of physici-
       ans between urban and rural areas.  It is designed to provide medical
       students of the Medical College of Georgia and Emory Universities, an
       opportunity to participate firsthand in the challenges and opportunities
       provided by medical practice in some of the smaller communities  of
       Georgia.  Its major purpose is to cause a greater number of young
       physicians to practice medicine in Georgia'a non-metropolitan areas.
       T,E@Sser objectives include: identifying some indicators of medical
       student interest in rural general practice, and to provide a learning
       experience for both preceptor and student.  The program will not
       provide students with academic credits toward graduation.  Initially
       it will consist of a group of ten students and will extend for  six
       weeks.  The selected students'tinie will be spent with the preceptor
       observing and assisting in his practice. They will  participate  in
       office visits, home visits, and hospital and clinical rounds,  plus
                                                                     hxiz i r, i qn




         GEORGIA Regional Medical Program        -4-             RM 00046  7/70.1

         is engaged.  An opportunity will also be given the student to
         participate in the community civic and family life.  The Georgia
         Academy of General Practice-has taken an active interest in the
         program and some of its members have volunteered to serve as
         preceptors.  The Rural Health Committee of the Medical Association
         of Georgia will make the final selection of all preceptors.  Students
         will be selected by the medical schools.  Criteria have been established
         for the selection of both preceptors and students.  Evaluation will have
         two basic purposes:  1) to determine the degree of effectiveness of the
         project in meeting its objectives, and 2) to attempt to identify some
         characteristics in medical students which would indicate potential
         interest in family medicine.  Several other GRMP projects will be
         utilized to continue the education of the physician and student during
         the preceptorship; the Visiting Consultant Program, the Interlibrary
         Copying Service, the Communications Network and the Area Facilities
         for Continuing Education.

         Second Year:  $11,400                       Third Year:  $15,000






                GEORGIA Regional Medical Program                                          RM 00046  7/70.1

                Summary of Operational projects currently being supported by GRMP

                                                                  Approved Project         Funded 2nd Year
                Project Title and Number                               Period                (Direct Cost)
                                                                                            7/l/69-8/31/70

                #1 - Short-Term Traineeships for Physicians            3 Years               $  106,985

                #2  -Post-Residency Training Pediatric Cardi-          I Year                    10,350
                     ology and Hypertension Renal Disease

                #3  -Visiting Consultants to Community Hospitals       3 Years                   24,500

                #4  -Interlibrary CoDvina Service                      3 Years                   23,333

                #5  -Columbus Medical Center - Emory University        3 Years                   42,843
                     Teaching Affiliation

                #6  -Communications Networl< for the Region            3 Years                 355,882

                #8  -Improvement and Coordination of Facilities-       3 Years                   93,333
                     Cardiovascular Diagnostic Services

              #10   -Cardiopulmonary Resuscitation                     3Years                  113,658

              #11   -Coronary Care Feasibility Study                   2Years                    34,194

              #13   -Statewide Cancer                                  3Years                  401,276

              #14   -Pediatric Pulmonary                               3Years                  170,810

              #15   -Training Medical Specialist Assistants            3Years                    68,485

              #17   -Communcations and Information                     3Years                    22,998

              #18   -Core                                              3Years                  761,321

              #19   -Development of Area Program                       3Years                    88,241

              #20   -Development of an Area Facility for                                    Funded Ist Year
                     Fontinuing Education                              3Years               7/l/69-8/31/70
                                                                                                 95,900

              #21   -Coronary  Care  Training                          3Years                    53,692

              #22   -Short-term  Training  in Cardiovascular           3Years                    26,116
                     Physiology  and  Medical Surgical Nursing

              #23   -Renal  Failure  Training and Demonstration        3Years                    37,819

              #24   -Teaching, Training & Demonstration in             3Years                    43,776
                     Hypertension and Nephrology

              Y@28  -Comprehensive Statewide Stroke                    3Years                    3,700

              #29   -Education and Service in Chronic                  2Years                    11,000
                     Pulmonary Diseases

                                                                               TOTAL         $2,623,512



                                             6                       Rm 00046   7/70.1
      GEORGIA Regional Medical Program

      Status of Unfunded Projects                                                    -
      #9 - Renal Dialysis and Transplant Program                        Disapproved
     #12 - Stroke Instruction Clinic                                    Disapproved
     #18S-Core Staff Supplement                                         Approved but Unfunded
     #25 - Development of Health Careers Council                        Disapproved
     #26 - Refresher Courses for Inactive RNS                           Disapproved
     #27 - Community Higli Blood Pressure Program for Atlanta           Approved but Unfunded
     #30   Planning for Area Cancer Facility in Augusta                 Approved but Unfunded



































                                                                   T)RMP/C,RB
                                                                   5/75/70





                                 #UMMARY OF REVIEW AND CONCLUSION OF
                                       JUNE 1970 REVIEW COMMITTEE

                                    GEORGIA REGIONAL MEDICAL PROGRAM
                                            RM 00046  7/70.1

                            FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


            General:  In reviewing this  Application  requesting  funding  for  the
                      development of  cardiovascular  area  and  stroke  facilities  and
            for medical student preceptorships in  rural  Georgia@,  the  Committee
            expressed some degree of frustration in their lack    of up-to-date
            understanding of the ongoing Georgia RNP.  The proposals appeared     to
            some members as a unique approach to subregionalization planning,     but
            the Committee was unclear about how these  efforts  related  to  the  local
            advisory group and present operational and core activities.
            The Committee appro@ed the application with specific conditions,     at  a
            greatly reduced budget and for two years  only;  one  project  was  disapproved.
            The request was for $376,872 the first year  and  for  $1,429,070  for  three
            years; the Committee recommended $100,000 for each of two years.
            Project #31 - Development of Cardiovascular Area Facilities.
            @critique: Committee recognized that the  activities  of  this  project,  which
                        are described in very general terms,  are  basically  planning  in
            nature and  questioned why such a program was not considered  a  part  of  the
            core activities; some observed it has  the  characteristics  of  a  supplement
            to core. It was questioned how  the  budget  which  appears  unrealistic  was
            derived, and on what basis the large  request  for  personnel@could  be  j  i-
                                                                                     ust
            fied. It was noted the comprehensive  services  to  be  provided  are  not
            defined and it is unclear as to whether this  can  be  interpreted  as  services
            to both in and out-patients.  It is not
                                                      explained how  this  project  relates
            to ongoing projects #8 - Improvement  and  Coordination  of  I,acilitibs-Cardi6-
            vascular Diagnostic Services and #19  -  Development  of  Area  Program.  Plans
            for phasing Out,6re described which indicate dependence.on the establishment
             f "some type of prepayment  mechanism",  however,  no  documentation  was  pre-
             eoted to support how realistic this will be, and no mention is made of.wliat
            will happ6n@io the planning staff when"'the project terminates.

            Committee agreed with the Ad Hoc  Cardiovascular  Panel  comment  that  the
            evaluation plan is restricted to  measuring  increases  in  services  available
             nd utilized, And that no assessment of  effect  on  morbidity  and  mortality
            *0 planned. Further the  reliability  of  need  assessment  procedures  and
            subsequent measurement of success is not adequatel  described.
                                                                 y

            in view of the concerns expressed the large  scope  of  the  project  and  the
            @iarge budget, the Committee reasoned that a logical  approach  would  be  to
            initiate the project on a pilot base in  one  or  two  Areas.  Upon  evidence
             bat the program is successful in these  areas,  expansion  into  other  areas
            would be appropriate;



             EORCIA Regional Medical Program          -2-              RM 00046  7/70.1
            Recommendation:  Approval I - at $100,000 for each of 2 years  for
                             Projects #31 and 32.  Because of the similarities of
            the programs the recommendation for this project is combine with
            recommendation for Project #32 - Development of Stroke Area Facilities.

            Project #32 7 Development of Str@--kq Area Fa ilities.
                       Committee observed this project  although related to stroke,
                       has the same basic design as Project #31 - Development  of,
            Cardiovascular Area Facilities and that many of the observations  made  of
            that project can equally apply to this one.  As with Project #31, Committee
            believed this project should be initiated as a pilot project in one or
            two areas and expanded to other areas as success allows.
            Recommendation:  Approval I - at $100,000 for each of two years for Projects
                             #31 and 32.  Because of the similarities of the programs
            the recommendation for this project is combine with the recommendation for
            Project  #31  Development of Cardiovascular Area Facilities.
            Project #33@- Short Term Prece2t6t TraininR Program to  Introduce  Medical
                          Students to Medical Practice in Rura

                       Committee and the Continuing Education Panel were in general
                       agreement regarding this project.  It was noted the educational
            needs are identified only in the sense of common agreement about  lack  of
              ral practitioners. There is no evidence presented that  there  is  a
              oi oi interested students. No reference is made to  oxperie  ces  in
            states where rural preceptorships is a part of medical school curriculums

            it was observed the evaluation is not realistic in that there is  no  test
            for,validity of the data, which can only be provided by time, i.e., do
            the students.enter rural practice?

            Committee did  ot agree.with Panel's belief that this project did not
            represent continuing education and that the appropriateness of this type of
            activity is questionable under the present guidelines.  It  was  concluded
            however, that this type of program should be supported either  by  the
            medical socie-ty or as an elective of the medical schools  curriculum.

            Recommendation-  Non-Apprbval I   No RMPS Funds Recommended.






                                          1',
             GEORGIA Repio6al Medical Program                 -3-               RM ooo46  7/70.1

             SUMMARY OF RECOMt4ENDATIONS


                                         Recommenda-
             Project Title and                tion             01           02       03       Total

             #31-Development of          Approval,-@l..@
                  Card]'-ovastular       along   with
                  Area Facilities        Project   Y@32
                                         for  2   years   $ioo,ooo     $100,000      -0-    $200 000
             #32-Development    of       Approval   I
                  Stroke Area            alonp,  with
                  Facilities             Project    #31
                                         for  2   years

             #33-A  Short   Term   Pre-  Non-Approval I       -0-          -0-       -0-         -0-
                  ceptor Tra             No R4PS Support
                  ProRram  to  In   ro-  Recommended
                  duce@medical     Stu-
                  dents to Medical
                  Practice   in   Rural
                  Georgia
                  TOTAL     APPLICATION  Approval with  $ioo,ooo       $ioo,ooo      -0-    $200,000
                                         conditions























                                                                              DRMP/GRB
                                                                              7/15/70



                               NW                  ---,  ------ .      -













































                0                                                                            0                                                                             0











                                                       C',       RVICI-'
                                    C   I' L I%,-I!,,D-(@CAL PI,, q i'@
                              0F k Stl@PPf,Ejjl,"NJ'Al, Ol'i@"Ri@TiOiNAL @,%NJ' A,PPI,ICATIO-N
                               (A Pi-i-vil-c-,gecl CoriiFit-tni,,@itioii)

        C'P,I,"Al-'ER Dl,@lTARE VALLEY 1,EGIONAI, @IFDICAL PROr@RA@l RM 00026 7/70.1
        Wynnewood I'@ouse                                            June 1970 Review Committee
        300  East  Lancaster   Avenue
        Wynnewood, Pennsylvania 19096

        Prg_grarii@orclina',-or: George R. Clammer, II.D.

        Re  o-sted           Ist  Yr.        2nd Yr.          3rd Yr.          TOTAL

        Direct Costs          $67,395        None             None             $67,395
        Indirect Costs        None           None             None              None



              TOTAL           $67,395                                          $67,395

        History:  In April 1967,this Region received its fi-rst planning grant of
                    $1,531,494 and its first operational award in April 1969, following
        a  site  visit  in  October  1968.  The  operational  award  of  $2,862,484  included
        support  for  Core  staff  and  support  for  initiating  five  operational  projects.
         ddi.tional projects were approved in a subsequent review cycle.

        In March 1970, Staff reviewed the Regioii'E; second-year operational continuation
        application  (1@/l/70-3/31/71-).  The  continuation  of  the   operational   projects
        evol-c-!,! little concern and, in general,  were  approved  at  the  committed  level.
        However, otaff had serious concerns about the basic organization (as described
        in the application) and the functions and activities of the large Core staff -
        in the Executive Director's office aiid.in the five medical schools.  The Core
        bud-et was approved at its committed level of $1,628,336 rather than the
        requested  $1,795,240,  with  a  $383,777  restriction  of  funds  imposed   ($340,000
        of wlii-cb is in the personnel category and $43,777 of which     'is in the subcontracts
        category). Further, it  was  decided  that  a  program  si.te  visit  should  be  made
        to the Region to explore the interrelationships of the Core staff with the
        projects, as well  as  tne  degree  of  coordination  among  the  various  staffs  of
        the  Core  components.  The  personnel  restriction  may  be  lifted  following   the
        program site visit, while the subcontract restriction was imposed peiidi.ng
        further clarification.  The Region is in its second operational year
        (4/l/70-3/31/71) at a total cost of $2,443,486 (d.c.) - $2,126,099 basic
        and $317,387  carryover  funds.  (Please  see  Ilistory  Supplement  for  a  bre@ikout
        of this total.)

        Pr@ent      lic,-ttion: This applicLiti.on requests oi-ir-,-ycir support  to  provide
                                equipment only for coronary care units in seven selected
        hospitals.  Direct costs only are shown in the project description.







                                                                           2                       l@Ni     00026.7/70.1.



                                                                                                   First      Year
               Project @I.9        Cc)rc)Li,,iry Care                for                             $67,395

               pi-bl)osal recii-ic,sts support  solely for the -pur(,.Iiise of
               coronary care ecluip,,ii@i-it  for se-%@cn selected coriiii)tii@i.ty
               hospitals in iNc)rtlieistc@ri-i Pennsylvania.             The Regi.oi-I ,LaLelc;
               that by providing coronary care equipment to these @;c,].ectecl
               satellite hospitals,  they                  provide the iitii--,c;es  (@,7110 have
               received,  or will receive,  special CCU Lraiiii-iig)                        the  tools
               to effectively apply the traini,i-ig at their I)oi-iic,-b@ise. hospitals.
               The  following cri.teria were the basis  for the selection of these
               hospitals:

                   1)   The   hospitals    indicated    an    interest    in    developi.i-ig    or    expanding    their
                       coronary care facilities.

                   2)  The   hospitals   indicated   a   COD)IIII-trf).eilt    to    securing    skilled    nursing
                       staff,  as            as   a   co,-P-.ni-tniciit   to   the   concept   of   rcgionalization
                       for tnis purpose,  as                  by    their     p@-irtici-pati-oii.(or     intention
                       to P--rti-cipete)  in the nurses'                        program.

                   3)  The    hospitals    have    the    potential.     capability     for     providing     services
                       vjliicli are presently lackirig or inadequate in the area.

                   4)  I'hc- hospitals would be Liiiible to           develop their potential
                       capabilities without additional- support.

               The  follc)7,,?ing hospitals ,,7ere sel@cte(i-

               B16o.msbur@,, Ilospital,                       Pa.    This hospital has 138 beds and serves
                                                                     a    population    of     approyiriiitely     70,000
               within   @-i fi'Lt--y-irti-le radius.    There   were   85   @iclniissioi-is    for    acute    Myocardial
               inflection in 1968 -i-icl 33 died.             Two   r@Lirse,,,   have   bad   special-   training   in
               coronary care,,in training programs -poiisored by GI)VI'l-I,IP.                   It  is   @laniic,,d   to
               provi.eie@ training for  four additional nurses within  the. rE,,xt year.                         Plans
               have been made and are bcii-rig                           for the col-ir,,tr  uction   of   a    new
                           CCU.


               Cn.-tdc@n I]Ljetten                             Lehighton       Pa.    In ties 130--bed hospital,
                                                                                      92   beds   are    devoted    to
               acute care.       The                serves  @l  PC)PL-,I.ati.011  03'  appro@li,-tiatel.y   60,000
               within a 2li-ri,.ile ricli.@is.     Y'ivc   nurses   are   trained   i-i-i   coronary    care    and
               five will be available  for training wi-thi-n the next year.   Plinr, are
               currently being                         to bLii.Icl @i -,-!-x-bc,.cl CCU.  Tlii-s   hospital    i-s
               also interested  in developing a trainiiic, pi-ogr@,,rl for i-lui.-ses whc) will
                                                                      C,
               wc)i7l@ in si@@iall hospitals  (1.00 beds or Ic@,c;s).








                             DEI.Al,@Al@," V!@1,1,1,"Y P,'I.@iP                 3                             R@l  000 26   7  /70.  1


                Pal-iiic@rtoii  iLos,@)!.                        1',i.     TliiE;   is a  65-becl hospital,
                                                                              serving  @l  popuInLion of
                30,000  to IiO,000                    a  20  to  25'-Dli-l.(-  radius.        In 1.968,  94
                pati-c,@nts   %,;crc,   a(Iiiiittc,.cl   for   @icutc,.   riyoc,-ircli@il   iiifarcti-on;   niiiet(@e-ii   died    during
                bospit@il.i.zation.'               nurses      are      currently      receiving      training      in       coronary
                care and  five will be avail-ablc- @@yitliin  the next year.                           Thc, hospital
                currently his  a  t@.)o--bc@cl  CCU and  plans are  in effect  to construct a new
                building @,)hicli wil.1 have a  total-  of  four coronary beds.

                f-t.  Joseph's Hosi)ital.,                                      This  hospital. has  105 beds  and
                                                                                serves     a     population     of     about      50,000.
                In    1968,     85     patients     were     admitted     for     acute     myocardial     infarctioil     and     21
                died     in     the     hospital.     Four     nurses     have     had     special     coronary     care      training
                and    five    @iclditic)iial    nurses    plan    to    t@ike    the  training     within     the     next      yeir.
                A    new    combined    intensive     care     unit--coroi-iciry     c@irc,.     unit     will     be     constructed.

                .Iyler Me,@iioriil- lios-I)i.t@il-,  Tun@-li@nnc)cl@,          -1   This    hospital.    has    62     beds     and
                                                                                    serves     a     population      of      17,000
                witlil.i-i a  15--@iii.1c,  raeLius.     T@.2enty-@j-x     patients     were     admitted     in     1968      with
                a   pi.-,i..@iiory    diagnosis    c)L'    myocardial    !-nl@arctioi-1.  @'en     of     these     patients     died.
                El.eveii of  the patients @,7c-i-e admitted @-71-th  a  secondary cli.@igi-iosis  of
                myocardial  j-nfarctioii;  eight  of these patients died.                             (lio,-.,7r-@ver,  not- all
                of these deaths %.2cre actrib@,.tc-d  to acute myocardial  i.i)farcLi-on.)                              Two
                nurses have had  specictl-  training  in coronary care. and  three Id(-Iitioiial
                nurses will be available  for  trqining wi-tliin the year.   The hospital
                currently     has     a     foLir--bed     combination     intensive      care      unit-coronary      care      Lil-lit.

                Wayne County                      Hospital,    hL4s.    79    beds    and    serves    a     population     of     30,000
                                                                 within a  20-mile  radius.   Forty-eight p@iti-ents
                were    admitted    in    10@68    for    acute    niyocarcli@)l    inf@irc,ti-on,    of    which     lli     died.
                I'@@yei)ty-five nurses have had  special-  tr@ii-niric, in coronary care and an
                additional  five nurses                     be available  for  training wi.tllin the next  year.
                This    hospital     has     a     new     four-bed     coi@il)inition     ii-ite-iisive     cai-e-cC)ronary     care
                uni.t,  but  only one bed  iE;  eciti-Lppc,et  for monitoring.

                    -- V@C -1 o@,s@@                                     Tti i                                      -Lid      serves.
                                                       Eill@e,-Pa            -S hospital. has  65 beds  a
                                                                         60,000    people    in    a     1.5-riiile     radius.     In
                196E@,  fifty--eig',)t patients were @idiiiitteet @,7itli a clicigi-iosis  of myocardial
                infarctioii;  eleven  of  these patients died.   None of the nurses have had
                special.  coronary cire  trctii-iinF,.              llo,-,,,,ever,  s).x        be     avii.li,bl-e     for     traininc,
                wi-thi-n  the next year.            Pati-c-,nts     with     acute     myocardial.     infarction     irc-     cai-ccl
                for  i.n  the general. hospital.               The    I)oF@pital     has     resuscitation     eqlii-pilielit-     in
                the   operating   and   c@iiic,.-gcncy   rooifis,   but   no   s'c,.cli3-   r,-toiiito-f-i@iig    eqLil-piTicnt    is
                                   C,                                               p
                                  Plai@s   are,   i-i-i   cffcc@t   to   construct   @i   nc@@-i   @,2ing,    consisting    of    a
                two-bcd  coronary care unit  adjacent  to @i  fo@ir-@becl  intensive,.  care unit.








                                                  V,,.LLI@"Y RI-'IP                     4                                    RI @l C)0020  7/70.1




                   LISTli@(-,  Ol-'  CURTIll,l']'  S'Jll,,'j'ITS  01'


                        A-  -  FU' 1)1'0  PrOJEC'-'S

                   Project                                                                                                 A.MOUllt  SLIPI)Ortecl
                   N u r,,i't) c,, rTitl@c@                                                                                Throtipli  3/31/71
                                                                                                                        F)a  ic                    Car


                   00               Core
                                        1)   Exectiti.vc Di-re-ctor                                                $    828,266
                                        2)   rahneflianii                                                               153,811@
                                        3)   Jefferson                                                                  142,3Oj2
                                        4)   Pliile..clelpliii  Ost:c@opatliic                                          106,860
                                        5)   University  of  Pciina.                                                    161@,.363
                                        6)   j'er@ipic@                                                                 113)297
                                        7)   I%Io@c.,an' s  ljc-eLical

                                                                          'J.10TAII    C, O'\. i                           $1,620-,336

                     I              Coronqry  Care  Traii-iin.-
                                    will@cs-Lar-rc  C-eiier,-,]-  illos;l)i@tal-                                          73,947                     17,391

                     2              Cc)r.oi-i@,i--y  Care  1'r@iiiii.yi-  -  Pe,-LOirig Hospital                          60,81,,.O                  20,961-,

                     3              General  Intensive                        Courses
                                                                                                                          94,278


                     4              Pliilo-dcl  Iiia  Re@ional-  Chronic  Pediatric
                                                   p            C,
                                    Pulraonary Disease  Prograiii                                                       1414 , 31i                   98)103

                     5              Retrairiii-t,-  Pi-c),irar,-.  for                   Physicians
                                    Telorii,an's  College  of  Peiina.                                                    75,884

                     6              Coronary  Care.  'j'rainiri-  Units                     Wi)-ri@irigtoii
                                    Medic,ql-  Center                                                                                                72     600

                     8              Centers  for  P@espiritory  Care                         llaliiicr,..-ann,
                                    Allc-iitoT.7i7i,  Vli-ll-,P-s-Barre                                                                              71,179

                   10               School  of  I,,adio'clier,-Ll)cutic  Tociiiiol-o3y  at
                                    Six  Cooperating                                                                                                 37,150







              (,'REATER DELliy@,7AI@,E VliLLF@,Y @IP     5                       Plit 00026 7/70.1

              IIISTORY SUPPLFIIEI\'T (ContiiiLi

              Project
              Nuniber    Title                                                Amount Supported
                                                                              ThLot-igli 3/:L /71
                                                                            Basic.           Carryover
              13         Renal Disease   Patient Support Program
                                                                             48,470
                         (Note:  This project was recoiiiinended for
                         approval for   three years during the
                         March 1970 review cycle.  The Division
                         is currently in the process of awarding
                         $48,470 for the first year.)


                                                    TOTALS               $2 126,099          $317,387
                                   CRAND TOTAL  (@ASIC & CARRYOVER)         $2,.443,486 (D.C.'O.)



































                                                                                            T NS@





                                                                                       on)
                                                             (A Privileged  Communi-cati

                                SLI@RY OF REVIEW AND CONCLUSION OF
                                     JUNE 1970 REVIEW COMMITTEE

                         CREA,TER DELAWARE VALLEY REGIONAL MEDICAL PROGRAM
                                          RM 00026 7/70.1

                         FOR CONSIDERATION BY JULY 197-0 ADVISORY COITNCIL

           General:  The Committee recommended that this supplemental operational
                     application (7/70.1) which requested  $67,395  d.c.o.  for  a  one-
           year program period, not be approved - no RMPS funding recommended.
           Staff reported on its review of the Region's second-year operational
           continuation application during March 1970.  The continuation of the
           operational projects evoked little concern  and,  in  general,  the  projects
           were approved at the committed  level.  However,  Staff  had  serious  concerns
           About the basic organization (as described in the application) and the
           functions and activities of the large Core staffs in the Executive Director's
           office and in the five medical schools.
           In June, 1970, a program site visit was made  by  the  Acting  Director,  RMPS,
           and other key Staff members to  the  Region  to  explore  the  interrelationships
           Of the Core staffs with the projects, as  well  as  the  degree  of  coordination
           among the various staffs of the Core components.
           Project l@19 - Coronary Care Equipment for Hospit.als in Northeastern Penn.
           Critique: The  Committee  expressed  ambivalence  regarding  this  project.  On
                       the one hand, it was agreed that the small amount of fun s
           requested for each of the seven hospitals may  have  the  effect  of  assisting
           these small hospitals in establishing coro   nary care units.  On  the  other
           hand, the reviewers believed that the modest amount requested (solely for
           equipment) would  ultimately  result  in  a  fee-generating  service.  Therefore,
           the hospitals should use local funds to provide the equipment.  It was
           questioned whether donors in the local  communities  had  been  solicited  to
           supply the equipment.
           The reviewers commented that the awarding of funds for this type of
           activity, in this area, would establish  a  precedent  for  a  national  program.
           The reviewers agreed with the Cardiovascular Technical Panel that the
           proposal is unapprovable on technical grounds.
           Recommendation:  Nonapproval - no RMPS funding recommended.









                                                                                      7/l/70


















            a                                                              a                                                              0














                                 REGIONAL MEDICAL PROGRAM SERVICE
                    SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                  (A Privileged Communication)


             Hawaii Regional Medical Program                RM 00001 7/70.1
             Harkness Pavilion                              June 1970 Review  Committee
             1301 Punchbowl Street
             Honolulu, Hawaii   96813

             PROGRAM COORDINATOR:    Masato Hasegawa, M.D.

             Requested
             Program
             Period             Ist Year     2nd Year      3rd Year    Total

             Direct Costs       $202,743      $99,168      $108,252    $410,163
             Indirect Costs        -0-            -0-         -0-         -0-


             TOTAL              $202,743     $99,168       $108,252    $410,163

             Note:  Attached to this summary is a Review and Funding History,
                   henceforth referred to as: R & F.H.

             HISTORY: The Hawaii Regional Medical Program received its i.nitial  plan-
                      ing award for $90,005 in July 1966 and its continuation planning
             award of $90,005 for 02 year in July 1967. In  November  1967  the  Region
             received a supplemental planning award, raising the total award for 02
             year to $148,764.

             Dr. 1,4asato Hasegawa replaced Dean Windsor Cutting as Program Coordinator
             in April  1968.

             An operational grant was awarded in September 1968 to  provide  continued
             support for the central staff, pending a site visit and Committee and
             Council review of the operational projects proposed.  A site visit was
             conducted on September 16-17, 1968. The site visit team found Hawaii
             to be a viable Reg4@on and recommended its operational application be
             approved.

             The November 1968 Council approved funding for nine operational projects,
             three of which were one-year projects. The  proposed  operational  activ-
             ities centered around the development of strengthened  continuing  educa-
             tion for physicians, nurses and allied health personnel within the
             Region.

             @n February 1969, Council approved the Regions first  supplemental  appli-
             (!ation at a level of $30,000 to develop a plan for extending  activities





                                                     -2-
                                                                         RM 00001 7/70.;l
               Rawai-i RMP
               to the Trust Territory before initiating activities in these widespread
               islaiAds of the Pacific-.  In making  this  award,  Council  sharply  redu  ed  the
               $100,.000 requested because of their concern that the Region might '.'spread
               inself too thin" and not concentrate its efforts sufficiently on building
               a Regional  Medical  Program  in  Hawaii.
               In August  1969,  the  Division  of  Regional  Medical  Programs  staff  negotiated
               the  02  year  operational  continuation  application  with  the  Hawaii  RMP.  The
               Region was awarded  $824,686  d.c.ocf  which  $336,101  was  designated  for  core,
               and the other for  support  of  eight  projects  and  the  Pacific  Basin  planning
               award. (Refer to R & FH)
               Around October 1969, the grantee  agency  was  changed  from  the  Univer@'stiy  of
               Hawaii to the Research Corporation of the University of Hawaii.
               The Region submitted  to  the  December  1969  Council  its  second  operational
               supplemental application requesting support for a core supplement and
               five projects(#12-#16).    Council Approved funding the core supplement and pro@
               ject #13-Rebabilitation in Castastrophic Diseases-Guam and Trust Ter         titory
               at a first year level of $93,768 (d.c.o.)  It also approved       if   projec,@:#12
               Treatment of  Cardiac  Arrest  in  Saipan"  with  no  additional  funds.  Action
               on the other projects was withheld  pending  a  site  visit.  (Refer  to  R  &  FH)
               A site visit to the Hawaii RMP was conducted on January 26-27,1970 as
               requested by the December Council.      Council asked  that  the  site  visitors
               look at the projects in the  December  Application  for  which  no  action_  was
               taken and at the total program development of the RMP.  The site visitors
               were impressed with the progress made by the Region in the past twelve months,
               Regionalization has moved forward at  a  reasonable  rate  and  the  pres&-6t  core
               staff is competent.  However  the  site  visitors  recognized  the  need  for  a
               full-time professional person with experience in the developement and
               implementation of continuing education activities on core staff.          It,was
               also apparent to the  site  visitors  that  Dr.  Hasegawa  needed  an  associate
               director  to  help  him  administrate  the  day-to-day  operations.  This  would
               allow Dr. Basagawa to be  free  to  spend  more  time  in  developing  the  philos-
               ophy and direction of the program.      The visitors  also  believed  that  it  was
               appropriate for  the  Region  to  begin operational activities in the Trust Ter-
               ritory  (Micronesia),  American   Samoa and Guam.
               The March  1970  Council  reviewed  the Region's  third  operational   supplemental
               application  which  requested   support for projects #17-#20.    Council   approved
               three of the projects at a first year level of $165,200 (d.c.o.) and:dis-
               approved one. (Refer to R & FH)
               PRESENT  APPLICATION:  This  is  a  supplemental  operational   application
                                      requesting  a  funding  level  of  $410,163  for  support
               of two projects.  The  projects  are  a  cervical  cancer  program  and  a  program
               for training of health aids in the Trust Territory.


               Project #21- Cervical Cancer Program for the Trust Terri@r             First   year
                              The December 1969 Council disapproved this project       $67'-.490
                                                                                      (Resubmittal.)






                                                                               RM  00001   71/70.1
               Hawaii RMP

                                   t it be returned for 17evis@(@ii.  'I'liev recommended that the
               and rc@cotiiiiieiided Llia
               revision include gre@iter consideration of the (-ethnic.-. problems,  the.  methods
               of collecting smears, qualit  y control in laboratory work and training of those
               wli(,, are to procure the smears. During the  Januarv  1970  site  visit  to  the
               F.-.egion it became apparent to the visitors that the  Hawaii  RMP  and  people  of
               ,'.Iicr(iiiisia regarded this activity as a highly important means of gaining vis-
               ibility and entry into the health care system of Micronesia.
               The proposal involves  the  development  of  a  @Cytologi-cal  screening  program
               for cervical cancer among  women who are over 25 years of age and who reside
               in Palau and Truk  districts  of  the  Trust  Territory  in  the  Pacific  Islands.
               An estimated 10,000 women  will  be  examined  during  a  three-year  period;  it
               is anticipated that thirty women will have i.nvasive lesions requiring
               treatment in Hawaii and about 100 will have preinvasive lesions and can
               be treated in the hospitals.
               During the first year of the project, two laboratory technicians will
               be given six months training in  cytotechnology at Hawaii:  funds for train-
               ing will be provided through the Comprehensive Health Planning Agency.
               At the same time two  clerk/stenographers  will  be  trained  on  site  by  a  con-
               sulting registrar; and all medical personnel including all medical officers,
               health aides and nurses will be provided in--service training in the procure-
               ment  of  smears  by  consulting  gynecologists.  The  cytotechnicians  will   read
               al-1 slides to identify those with abnormal cells and send those with an
               abnormal  reading  to  the  pathologist  located  in  Honolulu  for  confirmation
               and  final  classification.  In  addition,as  a  check  in  accuracy  of   cytology
               screening the cytoteclinician5  will  send  an  equal  number  of  "normal"  slides
               as a control group for the pathologist to read.  The consultant pathologist
               in Hawaii who reads all suspected slides will also assist in organizing
               the laboratory in the Palau and Truk district hospitals for cytological
               services and  conduct  periodic  followups  on  the  efficiency  of  the  screening
               system.  The  participation  of  the  Honolulu  pathologist  will   be   terminated
               after a certified pathologist is hi@red by the Trust Territory for a new
               hospital in Truk.  Once-,cancer  has  been  detected  and  verified  by  laboratory
               studies, the patient will  be  referred  to  one  of  the  six  district  hospitals
               in  the  Trust  Territory.  Patients  who  require  medical  procedures  which  can
               not be handled in the district hospitals are referred either to Guam or
               to  Hawaii.  For  educational  activities  it  is  anticipated  that  advice  and
               assistance from  organizations such as the American Cancer Society(Guam
               Branch) will be  solicited.,  For  evaluation  monthly  reports  will  be  made  by
               clerk/stenographers on the number of slides obtained for cytology from each
               district.  The  volume  will  be  matched  with  the  census  of  the  female  pop-
               ulation to which the project is applicable.  Once,the Regional Medical
               Program support has ended  the  program  will  be  supported  by  the  health  ser-
               vices program of the Trust Territory.  :Funds requested are primarily for per-
               .,;orliiel, consultants travel, equipment,  and  alteration  for  the  first  year.

               Second Year:  $54,054                        Third Year:  $60,'304



           Hawaii RMP                        -4-                     RM  00001 7/70.1

                                                                            First Year
           Project #22
                                                                  ain-       $135,253
                                                                   It pro-
           ing program in                                         ardized health
           vides a model                                          his application,
           aide training
           is a member of a community who provides preventive, curative, rehabilata-
           .tive and referral health care for other members of that community.
           The applicant states that health care services are inadequate for half
           of 9S,000 Micronesians who live on 100 island3 cver an expanse of three
           million square miles of ocean in the Trust Territory of the Pacific
           Islands.  In May 1969.,, coordinated efforts of t@.Regional Medical Pro-
           gram of Hawaii, Trust Territory Department of Health Services and the
           International Health Program of the University of Hawaii School of Public
           Health, led to the formation of a team to study the feasibility of a
           coordinated and standardized health aide training program for Micronesia.
           This proposal is an outgrowth of the study instituted by this group.
           The proposed plan is to hire a director and eight Micronesian health
           workers who will be trained as health aide teachers.  Three of the
           Micronesian teachers will be selected from the Yap district and one from
           each of the remaining five districts:  Palau, Marianas, Truk, Ponape,
           Marslialls.  By selecting a Micronesian health worker from each of the
           districts, it will be possible to coordinate all health aide training
           activities in the Trust Territory from the inception of the program.
           Each teacher could begin planning for a health training program under the
           director of this projeLt in his or her own district.  The director of the
           project and the Micron@sian health workers will initially spend five months
           at the University of Hawaii to develop teaching methods in the delivery
           of practical-health care services in Micronesia.  The Yap district
           was selected by the district directors of health services and the Trust
           Territory Health Planning Council as the site for a pilot project in
           health aide. training. In this pilot program 22 existing andfour new
           projected health aides will receive training and retraining.  The objectives
           of this proposal are to accompl.i.sh the following activities:  (1) Train
           Micronesian health workers to become health aide teachers for their own
           I)eoI)-Le; ()') Provide frequent retraining sessions for the existing health
           allies; ('3) Offer health career and basLc health information to high
           sr-lic)ol seniors as part of their academic school work;  (4) Train a
           selected number of high school graduates for health aide work; (5) Con-
           tiiiu@illy evaluate and adapt the health aide training program in the pilot
           I)rc)jecL Lo meet the stated goal of a standardized and coordinated health
           ai,le system for the entire Trust Territory of the Pacific Islands.  An
           evaluation to determine success in accomplishing the above objectives
           has beenbuilt into the project.  The majoritv of funds requ6sted for
           this proposal are under the item of personnel, equipment and travel.
           Second Year:     $45,114                          Third Year:    $47,948





                                                                          -5-                                 R"@l  OOG'Oll-   7/70.     1



                                                    RI-I'VIEI,,' Al\!D FUI@'DING IIIS'1'01"y


                    Yc,@ii.   PI,-tiiiiiiip   A@,7ard           7/l./66--G/30/67                          Dil7eCt  Cost               $  90.005
                                                                                                          Indirect  CoF@t
                                                                                                                                         -68,006
                                                                                                          TOTAL                       si.

                                                                                                          Amo-Liiit   of    Ax.7ard   $1.08,006

              2iicl   Yo@-tr   Pliiiniii@    A@-7@ird           7/l/67-6/30/68                            Direct        Cost              3,48,761,
                                                                                                          li)djrect        Cost          40,007
                                                                                                          TOTAL                       $1,9/i    771

                                                                                                          Less Unobl.igated
                                                                                                           B,il.ance                  $      72,474

                                                                                                          Auic)unt   of    A@,,@ird   $1-22,297

                                                                9/l/68-8/31./69                           Di.rE!ct      Cost          $33/i,].23
                                                                                                          Indirect         Cost          35,398
                          t@@ 0 I I
              (sj.tc! Visited oil                                                                         TOTAL                       $369,523,
              Scpt(@ii@oer 1.6-17,        1968)
                                                                                                          AmoLint    of     A,,?ard   $369,521

              ,ATiietidc,d  Iii-itial. Oper@iti-onal.           9/l./68"8/')I/69                          Direct        Cost          $837,903
                 _121.ic,itioii A-,,7.ird -                                                               Indirect         Cost          35,398
                                                                                                                                      $873,301
                                       6@9)                                                               TOTAL

                                                                                                          Ainount   of   A@,,,ai-cl   $87 3,  3@)].


              P'                                                            ic,.ct Period                 Fuii(lc-,d  (cico)
                                                                3       years                             (01.)    $3(,2,872          7 7t@@)

                                                                3       years                             (103)        40,3li8        7  ic)


              #3-llc,,Itli !lei-.-,oniie..l                     3       years                             (01)          9 937
                   Tr,i-iiiiiic,   1-ii    Oiicol-ogy


                   Rc,Tiz!i@!ic@ci  to-
                   Ilolic)I.Lil.u Itoiti,- C@ire
                                  Proc,riia

                                 tc)-
                   llotiic,  C@ti-c@ Triiiiiii@!,





                                                                6-                             IUI 00001-    @/70.1


                                             Approved Project       Period                Ftinded (dco)
               T  @Oi qL@
               #4-Coiiti.iitt-'Liig Lducation                year                         (01)    $  9=,467@-    7   mo
                   for Nurses in Patient
                   Settitigs

               .#5-Coiiti-iiuj-ng Edilcitioii           none                              (01)
                 .Program in Patliology

                            Tuiitor Itcgl--,Lry         none                              (01)        -0-
                   ExpaLisioii Prograni

               #7-Cardiopulitionary.                    3 years                           (01)       48,720      7   mo
                   Rcsusictatioii Training

               #8-Coron@try Care                        3 years                           (01.)      52,966 -    7   mo
                   Training Project
                   (Queens @ledical Center)
                                                                                                       @38,042   7   mo
               Jig-Coroiiary Care Unit                  1    year                         (01)
                   (Ililo Ilospital)

               #10-Coroiiai:y Care Unit                 1    year                         (O 1.)     44,649      7   no
                    (Wilcox i@fe@iiiorial
                    Hospital)

               #11-llkcgional Pediatric                 3 years                           (01)         210,852   7  rio
                    Pulmonary Progr@ini




               App@-i c@itij.oii--- --       3-969
               Revj,e-@7 Co,,iITII:Ltccc"
                           1.969 Coui-i@-ii.).

               Pacif ic l@,isiii                        5/l/69-8/31/69                                $30,000

                                                        10/l/69-9/30/70                   Direct Cost            $824,686
                                                                                          Indii7ect Cost             -0-
                               (Octc;l)cl:                                                TOTAT,





                                                                                          Fu-@ieictcl ((I(-o)
                   C(,J.-O                                                                (02)       $336,1.01

                                                                                          (02)       73,791.



                                                                                          (02)       1.8,667






                                                                -7-               l@t4 0000 1     7  70 .1




                                                                              Funded (dco)

                   #4-('c)t-itinuing Education                               (02)   $ 20,500 - 5 mo
                        of Ntirses in Patient
                        Settings

                   #7-Cjriopulnionary                                        (02)        70,049
                        Resuscitation Training

                   #s-Coronary Care Training                                 (02)    120,302
                        (Qtj(@ens Medical Center)

                   #9-(,'oronary Care Training                               (02)       9,550 - 5 mr)
                        (Ifilo Hospital)

                   #10-Cor(@nary Care Training                               (02)     44,649 - 5 mo
                        (Wilcox Memorial Hosipital)

                   #I.I-Regional Pediatric                                   (02)    114,596
                        Pulmonary Program

                        Pacific Basin                                        (02)        17,082

                   Second Operational Supplement
                   Application--(Novembet 1969
                   Re-view Committee--December 1969 Council)

                   @, @i- - C@t 11;

                   #IS-Core, Expansion of                   Approved bv Council             Funcied (dco)
                        Central Staff                       but Award is Pending
                                                            (01 yr.$87,387)

                   #12-Program for Treatment                Appro\7ed wiLli no
                        of Cardiac Arrest (Saipan)          funds

                   #13-Reliabilitation in                   Approved by Councit
                        Cat-astropfiic Di.seases            but award is Pending
                        (Guam and Trust                     (01     yr-$6,381)
                        Territory)

                   #14-Cervical Cancer Program              NON-APPROVAL      revision
                        for trust Territory                 is required

                   #15-Regi@)nal Cooperative                Approved by Council
                        Clieiiiotli(?rapy Program           but award is pending
                                                            (01 yr-$110,000)

                   #16-li,iwaii Tumor Registry              NON-APPROVAI,     revision
                                                            required




             Hawaii R,14P                           -8-                       00001 7/70.1


                                                                             Funded (dco)



             Council)



             i)@o@cts
             /117-)fawati 14 ass S(,reening           Approved by Council.
                  of (',Iiildrc@n for Heart           but award is pending
                  Disease                             (01 yr-$66,000)
             #18-Anti-Smoking Education               Approved by Council
                  Project for Hawaii                  but award is pending
                                                      (01 yr-$25,200)

                                                                     revision
             #19-Continuing Health                    NON-APPROVAL,
                  Education Council  of               required
                  Hawaii
             #20-Constant Care unit                   Approved bv Council
                  Guam Nlemorial Hospital             but award pending
                                                      (01 yr-$80,000)


             Fourth Operational Sui)i)lement
                 l@c a
                  )@,@@in Review Process


             LI @I)i e c t s

             #21-Cervical Cancer Program
                  For the Trust Territory

             #22-Trziining of Health Aides
                  in the Trust Territory


                                                                  0
                                                   BUDGET  REQULST  FOR
                                                              @IEDICAL PROC;RAill
                                                               CYCLE
                                                   jUI,Y REVIE@@
                                                                                         Alteration &                  Total
                                      Consulta,-it I:q uii)iiic-nt S@u    U)I@ies Travel  Renova@l'      Otlier      Direct  Cost
        E-Ct       Yr.   Pe  rs  o,,ine
                                                                                    $19,200  $4,962           $1,000   567,490
       Cervical    01          $24,623   S6,000      $7,205       $4,500
                                                        -          4,500        18,200           -         1,000        5'4,0511.
        Cancer     02       '-'5,854      4,500          2,990     5@00         18,000        ---          LIO-00       60,304
                   03       29,814        4,000                                 55.400        4,962        3,000       181,848
       SUB-TOTAL            80,291       14,500      10,195       13,500
                            25,441        8,840      48,218        9,400        40,904          -          2,450       135,253
   2   qealth Pid  01       24,982        5,480        -           2,400        10,252                     2,000        4D-,ll'@,
       Training    02                                                           11     553                 2@280        -7.948
                   03       26     335    5@480                    2@300
                                         19,800      48,218       14,100        62,709          -          6,730       2L8,315
       SUB-TOTAL            76,758
                            50,064       14,840      5:jz,423     13,900        60,104        4,962        3,450       202,743
       TOTAL       01                                                                           -          3.000        99,168
                   02       50,836        9,980        -           6,900        28,452                                 1,8  252
                            56  149       9  480       2  990      6,800        29  553         -          @?80        410,163
                            157,049      34,300      58,413       27,600        118,109         962        9,730










                                                                                                       DRMP/GRB 5/21/70





                                                            A Pri.vil-.-Ferl  CoTiiTo@ni.coti.,Dii.



                                  SUMMARY OF REVII?W AND CONCLUSION OF
                                       JUNE 1970 ITVIE14 COMMITTEE


                                    IIA@,,TAII REGIONAL MEDICAL PROGRAM
                                           EM 00001  7/70.1-

                           FOR CONSIDERATION BY JULY 1970 ADVISORY     COUNCIL

              General:  The Committee approved this application which requests $41-0,163
                          (d.c.o.) for a three-year program period at the requested level
                          to support Project #21 -  Cervical  Cancer  Program  for  the  Trust
              Territory (01 - $67,490; 02 -  $54,054;  03  -  $60,304)  and  Project  #22  -
              Training of Health  Aides  in  the  Trust     -Ltor (01  -  $135,253;  02  -
              $45,114;   03 - $47,948).

              Background:  The  December  1969  Council disapproved  Project  21  (then   Pro-
                           ject  #14)  and  recommended that it  be  returned  for  revision.
                           They  recommended  that  the revision include greater considera-
              tion  of  the ethnic  problems,  the  methods  of  collecting  smears,  quality
              control in laboratory work,  and  training  of  those  who  are  to  procure
              the smears. During the  January  1970  site  visit  to  the  Region,  it  became
              apparent   to the visitors that the Ilai-7a!.i Regional  Medical  Program  and
              people of Micronesia  regarded  this  activity  as  a  highly  important  means
              of gaining visibility and entry into the health care system of Micronesia.

              Project #21 - Cervical Cancer Program for tla.e Trust Tetr

              Cr,it:ique: The Committee believes  that  the  revised  application  has  been
                          considerably improved and recognizes that this project is
                          important to the  Hawaii  Regional  Medical  Program  because  it
              serves as   a -means for gaining visibility and  entry  into  the  health  care
              system of   that area. In  this  revised  application  the  Region  has  taken
              the expansive area and ethnic problems into consideration and will
              implement the program  in  phases.  Included  in  the  project  io  a  training
              program for medical officers, health aides, and nurses who will be
              taught to  obtain  smears.  Teaching  will  be  accomplished  by  a  consulting
              gynocbl6g!,st who -,7ill- go to MacDonald Memorial Hospital in Koror,
              Pol.au District, Trust Territory.  The Laboratory technicians will
              receive  six  months  training  in  cytotechnology  at  Pathology  Associates,
              Medical  Laboratories,  Honolulu,   Hawaii.  The clei.-I,-.sterio-ral)hers will
              be trained by a consulting  registrar.  All.  medical  personnel  v7l.ll  be
              given orientation in cancer of the cervix and the purpose of the
              project.    There will be a consultant pathologist in Hawaii i,71-ic) will
              read all suspected  s]-ides.  He  will  assist  in  organizing  the  laboratory
              in the Pol.au and  Truk  District  Hospitals  for  cytological  services  and
              conduct periodic folloi.,j-ups on the efficiency of the screci-tinE,,  system.
              For quality control. the cytotc-chnician will send  a  "norriial"  slide  with
              each  slide  identified  with  abnormal  ce lls  to  the  consulting  pathologist.






                IIA@4AII Regional @ledical Program              -2-                 RM 00001


                Committee sees this project's primary purpose as involvement and
                educational exposure for physicians in Micronesia.

                Reconmiendation:  Approval I

                lst Year                     2nd Year                    3rd Year
                $67,490                      $54,054                     $60,304

                Project   #22   -   Training for Health Aides in the Trust Territory.

                Critique:   The   Committee   recognizes   the   magnitude   of   the    geographic
                             problems which are present in this area in whi.ch'95,000
                             Micronesians live on 100 islands over an expqnse of
                3,000,000 square miles of ocean in the Trust Territory of the Pacific
                Islands.   It also recognizes the present limitations in medical manpower
                and the basic need of utilizing health aides which really function as
                physicians  assistants   in   order   to   meet   the   health   needs.   Committee
                believes that this project must have a qualified director who is coinpe-
                tent in training and supervision if it is to succeed.  This project is
                requesting $40,904 for travel and per them of instructors and trainees
                who must travel to and from Honolulu, Ha@,7aii- and the Micronesian islands.
                Committee expressed extreme interest in this program and suggested that
                its development be closely observed.

                Recommendation:  Approval I with the         condition that a project director
                                    who is competent in      training and supervision is employed.

                I-ct Year                    2nd Year                    3rd Year
                $135 253                     $45,114                     $47,948


                                      REVIEW CO@IITTEE FUNDING PT@,COMFNDI@TIONS

                                         Year                      u o-,; t@e          Recommended

                   21                      01                      $67,490                  $67,490
                                           02                     54,054                     54,054
                                           03                     60,304                     60,304
                        SUB TOTAI,                              $181,848                $181,848

                   22                      01                   $135,253                $135,253
                                           02                     45,114                    45,11.4
                                           03                     47 9@ll                     7,948
                        SUB TOTAT-                              $228,315                $228,315

                        TOTAL                                   $410,163                $410,163





                                                                           DIZ@TP GRB
                                                                           7/1-0/70


















            0                                                              0                                                              9









                                   REGIONAL MEDICAL PROGRAMS SERVICE
                             SUMMARY OF AN OPERATIONAL GRANT APPLICATION
                                    (A  Privileged   Communication)


            ILLINOIS REGIONAL MEDICAL PROGRAM, INC.                     RM 00061 7/70.1
            Suite 939                                                   June 1970 Review Committee
            122 South Michigan Avenue
            Chicago, Illinois

            Executive Director:  Morton C. Creditor, M.D. (Half-time        April 1, i970
                                      through June 30, 1970; full-time     effective
                                     July  1, 1970)

            Requested                lst  Yr.       2nd  Yr.       3rd   Yr.       TOTAL

            Direct Costs             $323,493       $452,833      $518,821        $1,295,147
            Indirect Costs             53,539         77,682          88,978         220,199


            TOTAL                   $377,032*       $530,515      $607,799       $1,515,346*

           *The applicant states that funds   available locally   for support are anticipated
            and pledged ($76,000 for the first year; $25,000 for the second and third
            year) by various official and voluntary agencies.  When received, these funds
            would be credited to the grant.

            History:  The Illinois Regional Medical Program was awarded its first planning
                      grant during July 1967.  Support was continued for the second year
            of planning Q168 - 6/69).  Included in the second-year award (as a part of
            Core funds) was $193,690 in earmarked funds, to support a hypertension
            screening program at Presbyterian-St. Luke's Hospital.  The target group
            of this program was the low-income population in a mile-square area adjacent
            to the hospital.

            The second-year award was supplemented three times.  One supplement provided
            support (again as a part of Core) for  an  educational  resource  study  at  the
            University of Illinois.  The objective of this program is to serve as a
            central assembly of specialized  personnel  and  materials  upon  which  various
            IRMP groups could call for  expertise  in  education,  communication  media  and
            evaluation methods.


            To provide time for Council to consider both the IRNP renewal application
            for Core support, as well as the Region's initial operational       application,
            funding was extended for a four-month period--from 7/69 to 10/69.  A
            preoperational site visit was conducted in June 1969.

            The August Council recommended renewal of the planning and Core support,
            with the exception of any new positions requested.  In addition, the August
            1969 Council recommended that  the  Region  became  operational,  with  approval
            of seven of the eight projects submitted.







                                                               RM 00061 7/70.1
          Illinois Regional Medical Program    -2-


          Due  to fiscal limitations, only the Core portion ($750,151 d.c.) was funded
          in November 1969.  Effective 2/l/70, the approved operational projects were
          funded.  A total of $1,585,643 has been provided for the first operational
          year.:.:'...@(See History Supplement for details)
          In March 1970 the Council considered an application which contained four
          new supplemental operational proposals (see History Supplement - Projects #9,
          #10, .#ll, and #12).  The entire application was deferred for a June 2 - 3,
          1970 site visit.  A preliminary site visit report will be available during
          the June/July review meetings.
          Effective July 1, 1969, the name of the applicant organization was changed
          from the "University of Chicago College of Medicine" to the "Illinois
          Regional Medical Program, Inc."
          On April 1, 1970, Dr. Creditor replaced  Dr. Wright Adams (retired) as Program
          Executive Director of the Illinois  Regional Medical Program.
          I-Ireseii@!i@l@- tion:  This supplemental application contains one new proposal
                                which requests support to initiate a Unified Health Informati
          Refert,al and CounselinR Service.  Direct costs only are shown in the project
          description.
          Projed"t #13  Unified Health Information.Referral and             Requested
                        Counseling Service   Welfare Council of             First Year
          Metrop6lit             This project proposes to establish         $323,493
          a service which will guide persons with health needs to the
          appropriate health resources in the most efficient manner;
          and will identify the unmet needs and deficiencies in the
          community's health resources in order to stimulate improved programs
          and provide data for planning and  research.
          The service will be available to the general public, to physicians and
          health care personnel, to social welfare agencies serving individuals with
          health:'-problems, providing them with a resource of up-to-date and complete
          information on the availability of health services.
          The service will be operated initially on an eight-hour basis, and as the
          operation expands, will provide twelve-hour service.  If warranted by
          demand, twenty-four-hour service will be provided.
          The specific objectives of this proposal are:  1) to establish a referral
          inventory of health services; 2) to link all.health referral services into
          one system that would be coordinated with the provision of direct health
          care; 3) to systematize referral procedures for the purpose of training
          staff and improving referral'techniques; andt4) to explore the use of the
          data, derived from the information and referral operation, for improving
          the delivery of health services and providing information for planning and
          evaluation studies.






              Illinois Regional Medical Program     -3-                RM 00061  7/70.1


              The project is divided into four phases. The first phase  is  devoted  to
              planning the program and gathering Background information and would take
              place within the first year of the project. There are  three  major  work
              components of Phase I which provide the basis for staff organization and
              the division of responsibilities:

                 1) Establishment of the Health Resource Inventory.  This includes
                    classification of health services, compilation of  health  resource
                    data; investigation of technological application to  store  and
                    retrieve information; and provision of information for  the  improve-
                    ment and planning of community health programs.

                 2) Coordination with Health Agencies.  This entails working out
                    cooperative relationships with the providers of health  care  -
                    neighborhood centers and related agencies - in order to gain
                    accurate information about their services and to gain their help
                    in developing the referral service; also, to insure that  the  referral
                    operation succeeds in helping the individual obtain the  needed  health
                    services.

                 3) Codification of the referral process. This  work  component  involves
                    development of typology inquiries; recommendations  for  record-keeping
                    and followup procedures; development of supervisory and training
                    procedures for the referral staff; providing information  and  making
                    referrals after the system becomes operational; and  providing  follow-
                    up on referrals made and participation in the  evaluation  process.

              The second phase of the project implements the mechanics  and  procedures
              of the referral operation.

              The third phase is focused on a trial run of the referral  system,  assessing
              how well it works and where corrections should be fed back into the design
              of the system. During this phase the referral  system  becomes  fully
              operational with a publicity program to inform the public of  the  service.

              Phase four deals with recommendations for future operation and development
              of the information and referral service.

              Three types of analyses would be employed to evaluate  this  project:
              1) empirical evidence of the work elements identified in the  project  have
              been completed; 2) qualitative analyses of professional and  technical  work;
              and three quantitative analyses of service, for example, volume and  type  of
              inquiries, and percentage of successful referrals.
              The major portion of the total first year budget ($323,493) is in the
              personnel category.  This accounts for $193,648 of the total budget.

              Second Year:  $452,833                          Third Year:  $518,821






                                                   -4-

         ILLINO@5  REGIONAL MEDICAL PROGRAM                                  RM 00061 7/70.1

                                           HISTORY     SUPPLEMENT

         LISTING OF APPROVED AND DISAPPROVED PROPOSALS TTITHIN THE ILLINOIS RMP

           A - APPROVED PROPOSALS
         PROJECT  'TITLE                                                     AMOUNT SUPPORTED (D.C,)
         NIINBER                                                             THROUGH 1/31/71

         Go        Core                                                         $    680,597
                     Hypertension Study - St. Luke's Hospital                      145,600
                     Education Support Resource Study                              174,500

                                                     CORE   TOTAL                 $1,000,697

          I        Organization of a Coordinated Home     Health Services
                  :.Pro ect in North Cook County                                    35,525

          2        Multiphasic Screening in Chicago Area Industrial
                  .-Plants to Detect Coronary-Prone Persons and
                   Individuals with Subclinical Heart Disease                      199,826
          4        Regional Coordinated Cancer Program                             108,950
          5        Radiation Therapy Treatment Planning Center                      24,300
          6        Macon  County  Stroke   Coordination   Program                   33,790
          7        Comprehensive Stroke Rehabilitation Program                     111,225

          8        Comparative Endoscopic Study and Training Prog      ram
                   @in the  Early  Diagnosis  of  Gastric  Cancer                   71,330

                                                        TOTAL                     $1,585,643


           B - PROPOSAL DISAPPROVED

          3        Establish Remote Automatic Monitoring of Patient Physiologic Data

           C - PROPOSALS DEFERRED TO INCLUDE A SITE VISIT (Ju-,ie 2-3, 1970)

          9        Community/University Heart and Stroke Program
         10        A Program for Continuing Education in Nephrology

         11        Chicago   Regional   Transplantation   Program

         12        A  Pilot  Program  for  a  Regional  Cancer  Educational  Program



                                                                                     DRMP








                                                      A Privileged Communication


                               SUMMARY OF REVIEW AND CONCLUSION OF
                                    JUNE 1970 REVIEW COM14ITTEE


                                 ILLINOIS REGIONAL MEDICAL PROGRAM
                                         RM 00061  7/70.1


                          FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


            General:  The Review Committee recommended that this supplements
                      operational application - 7/70.1 (cont aining one project  for
            which $1,295,147 d.c.o. is requested for a three-year program period)
            be funded for two years instead of the three years requested, in the
            reduced amount of $543,000 (d.c.o.) (with conditions as listed  below),
            rather than the $776,326 (d.c.o.) requested for these two years.

            This proposal was one of the subjects of the June 2-3, 1970 site  visit.
            The site visit team recommended approval in reduced amounts for three
            years contingent upon clarification of a number of issues (listed below).

            Project #13 - Unified Health Information, Referral and Counseling Serv ce-
                          Welfare Council of Metropolitan Chicago.

                       The Review Committee heard a report from the Chairman of  the
                       site visit team.  Committee agreed with the site visitors that
            this is probably a worthwhile project and believed that it is needed  in
            a Region which contains a complex Metropolitan Area.  Committee recommended
            approval for two years (instead of the three years recommended by the
            site visitors) and shared many of the same concerns  expresIsed by the site
            visitors. Committee agreed that these concerns needed  clarification  or
            justification before any funds are awarded.  These were:

                     The involvement of the Comprehensive Health Planning Agency  in
                     the planning of this proposal;

                 2)  That the applicant be required to submit a more detailed budget
                     justification with special emphasis on justification for personnel
                     and consultants;

                 3)  That the applicant agency be required to document its financial
                     involvement in the project,,

                 4)  That plans for support for future years (after termination  of
                     RNPS support) be made more specific;

                 5)  That both the amounts required under the subcontract  category
                     and the request for equipment during the first year be more
                     fully explained;








    10
            ILI,INOIS Regional Medical Program      -2-               RM 00061


                 6)  That the applicant work with the Community He
                     Information and Referral Service            currently being
                     funded in conjunction with the California RMP; and finally
                 7)  That a technical site visit be made at the end of the first
                     year.
            Recommendation:  Approval for two years in a reduced amount subject
                              to the contingents outlined above.

            Direct Costs Only:             lst   Year              2n.d Year
                                             $226,000               $317,000







                                     SMIARY OF RECO@2,IENDATION


            @ro@Ct
            Number          Title                   lst year    2nd Year   3rd Year

              13         Unified Health Informa-    $226,000    $317,000   h7one
                         tion  Refe ral and
                         Counselin,v Servic


            Year                                  TOTAL DIRECT COSTS

            01)                                       $226,000
            02)                                        317,000
            03)                                        None
                                        TOTALS        $543,000















                                                            DRMP/GP,B
                                                            7/6/70



                  . 2                                                                                                                                                                                                            m





















                   9                                                                                               I*                                                                                               0








                        REGIONAL MEDICAL PROGRAMS SERVICE
                     DIVISION OF REGIONAL MEDICAL PROGRAMS
                  SUMMARY OF AN OPERATIONAL GRANT APPLICATION
                           (A Privileged Communication)

          ILLINOIS REGIONAL MEDICAL PROGRAM INC. RM 00061 7/70.2 (fomerly 3/70.1)
          Suite 939                                February  1970  Review  Committee
          122 South Michigan Avenue                March 1970 Council
          Chicago, Illinois                         June 1970 Review Committee
          Executive Director:'Morton C. Creditor, M.D. (half-time, April 1, 1970
                              ,through June 30, 19704 Full time, effective July 1, 1970.
          Reque@@ted     Ist Yr.   2nd Yr.    3rd Yr.    4th Yr. 5th Yr. TOTAL

          Direct Costs $1,290,991  1,012,211  1,053,860  604,800  604,800  4,566,662
          Indirect Costs  214,937     229,549   241,769 122,766 122,766      931,787



             TOTALS     $1,505,928 1,241,760  1,295,629  727,566  727,566  5,498,449

          History:  The Illinois Regional Medical Program has been developing
                     and operating under planning funds since July 1, 1967.
          (First year:  July 1, 1967-june 30, 1968.)  Support was continued
          for the second  year  (7/l/68-6/30/69),  including  $193,690  ear-
          marked funds for a hypertension screening program at Presbyterian-
          St. Luke's Hospital. The  second  year  award  was  supplemented
          three times.

             Supplement I - supported a  systematic  study  of  continuing
                             education programs within the Region -
          University of Illinois.

             Supplement 2 - supported additional staff positions, to
                             develop liaison with the five medical schools
          and the School of Osteopathy; supported development of sub-
          regional planning; and supported ten subcontract planning studies.

             Supplement 3 - supported an educational support resource
                             at the University of Illinois,  to  serve  as
          a central assembly of specialized personnel and materials upon
          which various IRMP groups could call for expertise in education,
          communications media, and evaluation.

             To provide time for Council to  consider  both  the  IRMP  core
          support renewal application, as well  as  the  Region's  initial
          operational application, funding was extended for a four-month





                                               2 -          RM 00061 7/70.
         ILLINOIS Regional medical Program

         period (7/l/69-10/31/69), at the Region!8 current level
         of support.  A preoperational site visit was conducted
         on June 24-25,1969..
         In line with the recommendations of the site visit team,
         the August.1969 Council recommended renewal of the planning
         and core support, with the exception of new positions requested.
         In addition, Council recommended that the Region become
         operational, with some modifications of seven of the eight
         projects submitted (see last page for History Supplement).
          Due to fiscal limitations,,only the core portion, and
         necessary continuation portions of the grant, have been
         awarded.  $750,151 (D.C.) was awarded the Region for planning
         and core support for the period 11/l/69-10/31/70.  The award
         also provided:
           (1) Continuation funds for the Hypertension Project - $145,600
           (2) carryover authorization for a Valley Project
              Feasibility Study - $71,400
           (3) Continued support for the Educational Support Resource
               Study at the University of Illinois'- $174,500
         The total award for the third year was $1,141,651 (D.C.).
         Therefore, the Region is currently in its third planning
         year pending receipt of operational project funds to initiate
         these programs.
         Effective July 1, 1969, the applicant organization was changed
         from the "University of Chicago College of Medicine" to the
         present "not-for-profit" organization, the "Illinois Regional
         Medical Program, Inc."
         The Illinois Regional Medical Program's Regional Advisory
         Group is made up of 29 individuals.  Twenty-one members are
         medical doctors, most of whom are from the Greater Chicago
         Area.  Six task forces, as well as eight committees, have
         been formed within IRMP.
         Present         on:  This application requests support for
                               four new operational projects.  One
         project is in the field of heart-stroke; two are related
         to kidney disease; and one is in the field of cancer.  Direct
         costs only are set forth in the project description.







         ILLINOIS Regional Medical Program      - 3             Riv, 00061 7/70.2

                                                                Re@quested
                                                                First Year
         Project #9 - Cormunity/University Heart and            $695,149
                      Stroke Program.  The Chicago Medical
         School proposes E. five-year project to initiate a
         community-university heart and stroke program.  The
         complicated, innovative application is presented in
         three parts:


            (1) Central Administration
            (2) Stroke Care Project
            (3) Coronary Care Project

         It is proposed to establish a multidisciplinary program
         involving several departments within the medical school
         and its main teaching hospitals on one side; and, on the
         other side, several community hospitals and other health
         agencies within the western area of Cook County and
         neighboring Dupage County.

         The overall objective is %to make the resources of the  Medical
         School available to the community and its hospitals, through
         a cooperative program in the areas of heart and stroke
         prevention, treatment, and rehabilitation; and to  "feed  back"
         an analysis of the data so obtained to the Medical School
         so that the gap between medical excellence  (and  capability)
         and the community may be closed.  This is to be accomplished
         through three subobjectives:

            (1) To develop and support centers for diagnosis, treatment
                and teaching in community hospitals - to be interlinked
         with other centers and a coordinating center in a Medical School.
            (2) To train medical and paramedical  personnel  primarily
                for the participating community hospitals.
            (3) To develop a registry program for data acquisition
                and analysis which permits an evaluation of the program;
         and which, in the long-range future, may be added to other
         information in order to improve and/or develop methods of
         evaluation o  courses an( treatmen .


         Stroke Project. On page 308 of the application,  a  tracing  of
                          a typical stroke patient through  a  typical
         participating hospital is outlined. Paramount  to  the  success
         of the program will be a hospital coordinator who  will  work




      ILLINOIS Regional Medical Program      4            RM 00061 7/70.-2

                                                          Requested
                                                          First Year
      with the admitting physician in the referral of his
      patient through both an intramural as well as a
      traveling, extramural stroke project team.  In order
      to develop the necessary stroke teams, training will be
      provided for medical personnel - non-specialized physicians
      as well as for eighteen classifications of paramedical
      personnel (listed on page 309 of the application) .
      The training and continuing education will take place in
      programs already established such as the Mt. Sinai Hospital
      Medical Center's stroke demonstration "acute" and "non-acute"
      care units;Schwab Rehabilitation Hospital; and Fox River
      Extended Care Facility.  Continuing education through refresher
      courses and in-training programs will be conducted at
      participating hospital bases such as Christ Community Hospital
      and Gottlieb Memorial Hospital.
      In addition, home care services will be offered to selected
      stroke patients "who are not sick enough to be in a hospital,
      but not well enough to enroll as outpatients".  This service
      will be an extension of the already established home care
      service of the Mt. Sinai Hospital Medical Center.
      A multidisciplinary pilot screening clinic is proposed for
      the Martin Luther King Jr. Neighborhood Health Center.
      Essentially, the screening performed will be for hypertension
      and diabetes.  A stroke registry is proposed.
      Coronarv Care.  A detailed outline of the coronary care portion
                     of the proposal begins on page 335 of the
      application. Part I outlines core services to peripheral
      units such as EKG interpretation by telephone, heart sounding
      interpretation by telephone, treatment consultation, continuing
      education, training, rotation of nursing and medical staff
      by exchange method, electronic engineering consultation,
      evaluation and analysis of data and quality control unit audit
      team.  Part II describes the core unit physical facilities
      (Mt. Sinai Hospital) which are to be utilized in this portion
      of the proposal.
      Each of the participating hospitals plans to appoint a committee,
      selected by its own medical staff and administrators, to






          ILLINOIS Regional Medical Program -5-            RM 00061 7/70.2


          coordinate project activities within its own
          institution.  Also, it is the appointed member of
          that committee who will- act as his institution's
          liaison coordinator between the institution and the
          Chicago Medical School.

          Second Year:  $572,990       Third Year:  $614,800
          Fourth Year:  $604,800       Fifth Year:  $604,800

          In summary, the applicant states that the intramural-
          extramural project to initiate a community/university
          cooperative heart and stroke program provides for regional
          cooperative arrangements; the interchange of personnel;
          maximum utilization of existing facilities; community-
          wide benefits; services to persons now less adequately
          served than others; continuing education of personnel;
          innovative provisions for rehabilitation and health-care.


          Critique: February 1970 Review Committee.

          Project #9 - Cornmuni-tV/Universitv Heart and Stroke Program.
          Critique:  The Committee expressed ambivalence regarding this
                    project.  While it was agreed that the two-fold
          program in the areas of heart and stroke prevention and/or
          treatment (with feed-back of the analysis of data obtained to the
          medical school) appeared to be a worthwhile endeavor for this
          large, complex Region, the proposal was presented in an ambig-
          uous form.  The justification for combining two separate
          programs under one common administration (which is based on
          lowering costs) needs further explanation.  it was noted that
          the sole preventive stroke aspect.would be conducted in the
          Mal-t.in f,uther Ki,nq Jr. Neighborhood Center in Chicago, yet the
          pi-opos@ll sliow(,,,.i no endorsement from the Center.  In fact, there
          was no evidence presented to show that the institution had been
          involved in the planning of the program.  While admitting that
          some of the activities proposed were new and innovative, the
          committee- aareed with the conclusion of the Ad Hoc Cardio-
          vascular Study Panel that the proposal left many questions
                                                    mmended that an expert
          unanswered.  Thereforeo the committee reco
          site visit team review the proposal and explore the following
          points:
             1) Five years of support was requested.  This period of time
                was considered excessive.
             2) A breakdown of the budget request into various segments
                should be obtained which would show a more clearly defined,






                                                      00061 7/70.2
      ILLINOIS Regional Medical Program -6-         RM


      identifiable pattern of the different phases and  participation
      by the various community health centers and hospitals.
        3) There should be further justification of  the  involvement
           of neighborhood health centers in the planning  of  the
      program and of the planned use of the lower socioeconomic
      group for paramedical training in these centers.
        4) The possibility of terminating the coronary care training
           portion of the program at the end of two years.
        5) If this program is f@nded, some concrete methods of
           evaluation should be established to ensure  a  complete
      review of the program at the end of two years.
      Recommendation:  Deferral, including a site visit.


      Project #10 - A Program for continuing Education        $162,257
                    in Nephrology.  NorthWestern University
      proposes a three-year project to establish a continuing
      education program in ndphrology.
      The projected program is a cooperative effort to establish
      nephrology units in Chicago and three other areas of the
      State - Springfield (Downstate), Peoria (Western), and
      Evanston(Northern).
      Initially, facilities and personnel of eight major hospitals
      within these areas (subregions) will serve as training  centers
      for the program.  These are:  Northwestern University Medical
      School, Passevant, Wesley, V.A. Research, Childrens',  Evanston
      Memorial (Springfield), and St. Francis Hospital of  Peoria.
      An advisory group composed primarily of nephrologists from
      the cooperating hospitals has been established.  Over the
      years as new nephrology units are established, they will  be
      incorporated into the program. Through its  present  faculty
      and facilities, Northwestern University is in a position  to
      offer valuable support and guidance to the program.
      Nine major objectives are set forth; seven are concerned
      with the provision of training for physicians, to improve
      the quantity and quality of care offered to the patient with
      kidney disease.





             ILLINOIS Regional Medical Program    -7-              RM 00061 7170.2


                                                                           Requested
                                                                           First Year
             Funds are requested to support 50% of the time of
             a project director at Northwestern who will have the
             responsibility for the overall coordination of the
             program.  In addition, 12.5% to 50% time is requested
             for@four project coordinators and two subregional
             coordinators, each of whom will work in one of the
             hospitals which has major training capabilities.  It
             will be the.responsibility of the coordinator to  direct
             the program at his institution as well as at  affiliated
             units throughout his Region.

             The Advisory Committee will select prospective  trainees
             and (with the help of the individual trainee)  determine
             the most effective training program.  Time limitations on
             practicing physicians have been considered. T  ere  ore,
             a comprehensive training program is proposed for two-week
             segments until completion of time equal to an ideal  three-
             month to six-month period.  Specific training will be
             offered in the following methods and techniques:  1)  renal
             biopsy; 2) assessment of renal function; 3) drugs; 4) hemo-
             dialysis. Training for nurses and technicians  would  be
             offered for at least a three-week period.

             Initially, the program is organized to train 16  physicians
             each year - for a six-week period, divided into two-week
             segments. Also, over a period of a year, a total  of  34
             nurses and 34 technicians will be enrolled in three-week
             training courses.  It is intended that the academic, basic,
             and specialized instruction be given at the  university-
             affiliated institutions, while dialysis training and  other
             practical procedures would be taught at all of the participating
             institutions.  It is envisioned that this continuing education
             program will also relate to the Chicago  transplantation
             program (Project #11) described below.

             Second Year:  @181,948               Third Year:  $191,883

             Critique:  February 1970 Review Committee.

             Project #10 - A Program for Continuing Education in Nephrology.
             Critique: Committee agreed that this activity is in  keeping  with
                       the Region's plans4for continuing education.  The objectives
             outlined in a complex program were considered to be clear, well-defined,
             and attainable.  The Committee noted that the Continuing Education and
             Training Panel believed that this project was feasible under  spec   c
                         -, - - ---, --- - -t- ---,2 ---- -C #-I,- 13@--i I . -n@a-y-na anti hpl i r-upti that



      ILLINOIS Regional Medical Program'  -8-              MM VVVI.I.L II %I.
                                                             -@ri- - t o
                                                      ti    4i
      a site visit should be made, with special atten  on
      clarifying issues raised by  each review group, specifically:
         1) What plans have been formulated for continued support
            after RMP funds are terminated?
         2) Is additional information necessary with reference to
            the nursing education component of the project?
         3) The major emphasis appeared to be on  the  dialysis
            procedure.  Would it not be more prudent to expand the
      project to include other disciplines?
         4) Also, would it not be more feasible (even though it would
            require a change in methodology) to expand the program
      to insure a more comprehensive approach to the care of the
      renal patient?
         5) A clarifying statement was needed showing exactly how
            the University was to be involved in  the  project.
         6) A clarification of the proposers' actual meaning of the
            terms "nurse, technician and physician trainee" would
      be helpful.
      Recommendation: Deferral, including  a  site  visit.
      Project #11 - Chic    Reqional Trans  antation           $384,430
                    Pro@am.  This three-year proposal was
      developed by the Chicago Medical School,  the  University
      of Chicago, the University of Illinois  and  Northwestern
      University Medical School.
      The proposed program (for leukocyte typing, organ
      procurement, and organ distribution)  would  provide
      a substructure for organ transplantation in the
      Chicago Regional Area.  Renal and heart trans-
      plantations are currently-being performed  at  eight
      medical centers in Chicago.  It will serve as a
      rallying point for both interinstitutional and intra-
      institutional cooperation.-in a number of  important
      basic science areas contributing to the  success  of
      organ transplantation. The  procurement  of  cadaver
      organs, plus their preservation and  distribution,  will
      constitute one important aspect of  the  program.  Organs
      will be salvaged at various medical centers  in  Chicago
      and later in southern Wisconsin.  (The Wisconsin RMP has
      had under review, since May, 1969, a similar proposal
      which has not yet been acted upon and is awaiting
      Council policy clarification.)

           9
      Special preservation equipment will  facilitate  storage
      of the organs long enough to select an appropriate patient
      in need of the organ.  Kidneys will be the principal
      organs transplanted but hearts, livers, and  lungs  will
      also be made available.




            ILLINOIS Regional Medical Program -9-                 RM 00061 7/70.2

            The Selection of the appropriate recipient for any organ
            will be determined by a list of criteria to be established.
            High on the list of crite:ria for determining  the  appropriate
            recipient will be the results of leukocyte typing of both
            the donor and the potential recipient. All prospective
            recipients are to be studied by one of four standardized
            leukocyte typing laboratories.

            Education of the entire medical community regarding trans-
            plantation is expected to lead to more judicious patient
            care, including referral to the transplantation centers,
            when this is indicated.


            Second Year:  $244, 984        Third Year:  $247,177
            Critique: February 1970 Review Committee

            Project #11 - Chicacfo @ional Transplantation PEogram.,

            Critique: The Committee agreed that this  project  described  a
                       very complex program. Also, the  objectives  of  the
            proposal are worthwhile, attainable, and reflect a keen
            awareness of the problems and complexities involved  in  tissue
            typing.

            An inherent weakness in the project was the lack  of  reference
            to possible plans for exportation of kidneys to other areas of
            the U.S.  It was concluded that, if exportation was not planned,
            the requested budget could and should be substantially reduced.
            Further, the Committee was concerned with the  inadequacies  of
            this proposal as noted by the Kidney Disease Control Program in
            its review of the project.  These are:
               1) A failure to document the real need for this service.
               2) A lack of planning to widen the recipient pool,  and,  if
                  this is done, whether it will be accomplished through
            home or center dialysis.
               3) The necessity for additional typing centers when  there
                  are already two excellent typing  laboratories  operating
            in the Region.
               4) Failure to describe specific'organ preservation tech-
                  niques.
               5) Failure to document the techniques of interinstitutional
                  sharing of organs to be used for transplantation.
               6) Method of description of program evaluation was weak.
               7) The large amount requested for initial costs, in  terms
                  of personnel and equipment, needs much greater justi-
            fication.
               8) In line with item #7, the entire budget was  considered
                  extremely excessive for this type of activity, in  this
            particular geographic area, and should be fully  described  and



      ILLINOIS Regional Medical Program -10-            RM 00061 7/70.9
        9)' Further assurance is needed that the  activity  would  be
           carried on after Federal support is withdrawn.
       10) Rather than merely relying on  assurance  of  cooperation
           from the deans of medical schools,  evidence  should  be
      presented which will- prove that cooperation among the  actual
      personnel involved in the transplantation effort  will  really
      occur.
      In addition, the Committee was interested in  learning  about
      detailed plans for the continuing education facet  of  the
      transplantation program.
      After a considerable amount of discussion and due to lack of a
      clearly defined DRMP policy on projects of this type, the
      Committee recommended that this project be  site  visited.

      Recommendation:  Deferral pending a site visit.
      Project #12 - A Pilot Program     a Regional             $49,155
                    Cancer                   .  This
      proposal was initiated by the Cancer Committee of
      the Illinois Regional Medical Program, developed
      with the North Suburban Association for Health Resources,
      and will be administered by the Evanston Hospital
      Association.  The pilot program will be established at the
      Evanston Hospital.  The proposed activity will involve
      fourteen member hospitals of the North  Suburban  Association
      for Health Resources (all located in North Suburban Cook
      County), plus two participating institutions which are
      located in the Downtown Area of Chicago.
      Support is requested, for one year, for a pilot study to
      demonstrate the feasibility of a cancer education program
      within the Region.  In addition, support is requested for
      three months (of a second year) so that an evaluation may
      be performed.
      The main thrust of the proposal is  cancer  education  for
      physicians, to be implemented by the  establishment  of  a
      central cancer registry. The  registry  would  accept  and
      record information on cancer patients from the sixteen
      participating hospitals.
      A secretary in charge of medical records in each hospital
      (working with the pathologist), would obtain pertinent
      information on cancer patients daily; record it  on  a  basic
      information sheet; (suggested form:  American College of
      Surgeons Cancer Reporting Sheet); and forward  the  forms  to
      the office of the director of the  program.  In  addition  to




            ILLINOIS Regional Medical Program                     RM 00061 7/70.2

            auditing the reports to insure their  accuracy  and  completion,
            the director's office will provide for the transfer of the
            reported information to punch cards.  The education program
            in the individual institutions would be based largely on the
            printout data which would flow back to  the  subregions,  to
            the hospitals (and the professional staff of the hospitals),
            on a periodic basis.

            For the purposes of the program,  each  hospital  would  establish
            itself as part of a subregional group of hospitals     These
            subregional groups would consist of  three  to  fifte;n  hospitals
            all in a relatively small geographic area.  A liaison fellow
            would be assigned to each subregion.  He would serve
            as cancer advisor (on request), to individual hospitals,
            and also arrange annual or semiannual  cancer  programs  for
            hospital staff. He would also  provide  information  to  the
            Cancer Committee of the Illinois  Regional  Medical  Program
            on the quality of cancer care in his area.  Anticipated
            benefits for participating hospitals are:

               (1) To educate professional staff regarding the
                   desirability of a cancer education programi

               (2) To upgrade the cancer ed ucation program in hospitals
                   which have not previously had a cancer registry.

                                    1
               (3) To develop common standards for  cancer  programs  in
                   the various hospitals.


            Second Year:  $12,289
            (3 months)

            Critigue:  February 1970 Review Committee


           Project #12 -.A Pilot Proqram  for  a-Regional  Cancer  Educational
                         Program.

           Crit@ue:  The Committee was impressed with the outreach of this
                      pilot project which  would  eventually  involve  sixteen
           participating hospitals (all types,  including  hospitals  in
           ghetto and underprivileged areas) with a total  bed  capacity  in
           excess of 4,300.  Approximately 4,000 new cancer patients are
           seen each year in these hospitals.  The proposed cancer education
           program would be available to some 1,450 members of the pro-
           fessional staffs in the cluster of hospitals involved.    The
           Committee noted that this project was engendered by the    Cancer
           Committee of the Illinois Regional medical Program and,   if  the
           results were successful, could easily serve as  a  prototype  for
           ot'hpr similar nrocrrams throughout the Reaion.





    ILLINOIS Regional Medical Program           -12-              RM 00061 7/70.2

    it was further noted that this plan included a format modification of a
    successful program developed by the Intermountain Regional Medical
    Program.  The success of the Intermountain program is attributed to the
    fact that the education program is centered  around  information  largely
    supplied by the participating hospitals.
    fhe Review Committee believed th4t this was a well-conceived program
    .inder capable direction.
    Recommendation:  Approval in time and amount requested.
    )irect Cost only:         lst Yr.            2nd Yr. (3 months)
                              $49,155            $12,289

    )verall Recommendation:  February 1970 Review Committee.

    @eneral:  The Review Committee recommended that this Supplemental Opera-
              tional Application 3/70.1 - containing four individual projects
    and requesting $4,566,662 (D.C.O.) for a five-year program  period  -  be
    .3artially funded at $61,444 (D.C.0) to support Project #12 in  the  time
    and amount requested (15 months).  Committee believed that action on
    '3rojects #9, #10, and #11 should be deferred pending a site visit.  The
    last site visit to the Region was conducted on June 24-25, 1969.

    4arch 1970  Council Action:

    )eferral  including a site visit and with the suggestions  of  the  Review
    Committee.  Note:  The Council agreed generally with the Review Committee
    Concerning  project 12 but recalled the difficulties in inter-institutional
    Cooperation  within the Region.  They recommended that the entire application
    )e included in  the site visit.

    ;ite visit - June 2-3, 1970.
    N report will be available for the June 1970 Review Committee.





         ILLINOIS Regional Medical Program     -13-                 RM 00061 7/70.2

                               HISTORY SUPPLEMENT

         LISTING OF APPROVED AND DISAPPROVED PROJECTS WITHIN THE    ILLINOIS RMP
         (The approved projects are not funded due to fiscal limitations.)

           A - Approved Projects
         Project                                            Amount Recommended
         Number   Title                                     First Year

         #1       Organization of a Coordinated Home
                  Health Services Project in North Cook
                  County                                     $  35,525

         #2       Multiphasic Screening in Chicago Area
                  Industrial Plants to Detect Coronary-
                  Prone Persons and Individuals with
                  Subclinical Heart Disease                   199,826

         #4       Regional Coordinated Cancer Program         104,950

         #5       Radiation Therapy Treatment Planning
                  Center                                        24,300

         #6       Macon  County  Stroke  Coordination  Program  33,790

         #7       Comprehensive Stroke Rehabilitation
                  Program                                     141,255

         #8       Comparative  Endoscopic  Study  and  Training
                  Program in the  Early  Diagnosis  of  Gastric
                  Cancer                                        71,460



                    TOTAL AMOUNT - APPROVED BUT               $611,106
                      UNFUNDED PROJECTS


            B   Project Disapproved

         #3       Establish Remote Automatic Monitoring of
                  Patient Physiologic Data




                                                                     DRMP
                                                                   6/l/70







                                                      A Privileged Communication



                             SUMMARY OF REVIEW AND CONCLUSION OF
                                  JUNE 1970 REVIEW COMMITTEE

                              ILLINOIS REGIONAL MEDICAL PROGRAM
                                      RM 00061  7/70.2

                        FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL

          General:  The Review Committee recommended that this Supplemental
                    Operational Application - 7/70.2 - containing four individual
          projects and requesting $4,566,662 (d.c.o.) for a  five-year  program
          period - be partially supported for a three-year period, in  a  reduced
          amount of $1,047,532 (d.c.o.). This amount will  support  Project  #10
          in time and amount requested; Project #11 in the time requested but in
          a reduced amount; and will support Project #12 in the time  and  amount
          requested. Committee believed  that  action on Project #9  should  be
          linon-approval - revision required."
          All four individual projects were  reviewed during the  February/March,
          1970 review cycle. At that  time  Committee recommended approval in
          time and amount requested for Project #12.  Deferral to include a
          site visit was recommended on Projects  #9, #10, and #11.

          The March 1970 Council recommended that Project #12  be  included,for
          review as a part of the site visit. The site visit  was  conducted  on
          Juive 2-3, 1070. The Chairman of the team presented the findings to the
          Review Committee.

          Project #9   Community/University Heart and Stroke Program.
          Critique: The Reviewers, in agreement with the site  visit  team,  con-
                     sidered this to be an enormously pretentious proposal.  While
          it Appeared to be A comprehensive program including  many  cooperating
          agencies and facilities and involving the community, it  was  difficult
          to differentiate between the three activities proposed - coronary care,
          stroke, and screening. While recognizing the  possible  benefits  and
          economies of sharing personnel, the Reviewers felt that  the  current
          central administrative setup was too complex to  function  effectively
          and that this program,might better be presented as two separate proposals.
          During the February/March review cycle, an important concern  of  the
          Reviewers was the lack of involvement on the part of the,Martin Luther
          King, Jr. Neighborhood Center in the planning of this  proposal  (where
          the sole preventive stroke aspect was to be conducted.)  The site visit
          team members shared this concern.







                                                                    RM  00061
            ILLINOIS Regional Medical Program     -2-


            Members of the Review Committee also agreed with the site visitors in
            regard to the diagnostic screening aspect of  this  proposal.  If
            prevention and detection are basic objectives, it was believe. I that a
            larger screening component would be necessary to insure the success
            of the program.
            The Committee believed that. the only salvageable aspect of the
            proposal might be the coronary care training  aspect.  However,  due
            to the complex budget which was presented, it was  impossible  to
            separate this activity.  In fact, the entire budget request was con-
            sidered ill-defined and unidentifiable.  Also,  the  evaluation  component
            (especially for the stroke portion) had not been  clearly  outlined.
            In recommending "non-approval - revision required,"  Committee  con-
            curred with the site visit team in suggesting that the applicant separate
            the interwoven parts of the program (with a realistic budget for each
            division) before resubmitting the proposal for consideration.

            Recommendation:  Non-approval - revision required.
            Project #10 - A Program for Continuing Education  in  Nephrology.
            Critique:  Committee heard the report of the site visit team Chairman
                       regarding this proposal.  During the interim between the
            February/March review cycle and the June 2-3, 1970 site  visit,  the
            applicant had prepared a written statement in response  to  issues  raised
            by the review group.  The Committee, as well as the site visitors, was
            satisfied that the statement spoke to the issues.  It was noted there
            are nine major objectives and two minor objectives which  are  to  provide
            contir.uing education in nephro.logy for physicians, nurses, and other
            allied health personnel.  Substantiation of a need for this type of
            education was well-documented and appeared to be relevant.
            Although the objectives for the physicians were  strong,  the  educational
            objectives for nurses and technicians appeared to be generalities and
            would, therefore, be hard to evaluate.
            The proposal will complement regionalization.  Its activities are not
            limited to dialysis.
            In recommending approval in time and amount requested, the Committee
            felt that the Region should be advised of the Reviewers' concern
            regarding a lack of involvement of field nurses in both the planning
            and the continuing education program proposed. Also,  it  was  noted  that
            $3,500 is requested during the first and second year,  and  $4,000  during
            the third year, for staff and trainee travel.





            ILLINOIS Regional Medical Program       -3-           RM 00061


            Recommendation:  Approval in time and amount requested.

            Direct Costs Only:         Ist Year           2nd Year         3rd Year
                                       $162,257           $181,948         $191,883

            Project #11 - Chicago Regional Transplantation Program.
            Critique: Committee noted that during the February/Marth  1970  review
                      cycle, a series of ton important concerns  regarding  the
            inadequacies of this program had been expressed.
            The program was originally reviewed by the Kidney Disease Control
            Program. The original purpose of the proposed program was  to  provide
            Chicago and the Southern Wisconsin Area with a cooperative plan for
            organ procurement and preservation; and, in addition, to establish  a
            comprehensive leukocyte typing and organ distribution operation.
            During, the time this program has been in the review process, a compre-
            hensive renal program was in the process of being funded through  the
            Wisconsin Regional Medical Program.
            The Committee was advised by the site visit team Chairman that  the
            present Chicago program is currently in operation and the  awarding
            of funds would serve to enhance and expand the current  program.  Four
            medical schools have operated through eight medical centers in  the
            Chicago area in carrying out a limited transplantation  program.  The
            primary purpose of the requested P@ funds is to expand  this  program,
            due to an increasing demand and the development of more  sophisticated
            technology. However, the Committee believed that because this  is  an
            on-going prog ram most of the equipment needed should already be
            available and therefore should not be supported out of  PMS  funds.
            The Committee agreed with the site visitors that the approval of  this
            request would serve to cement cooperative relationships among the
            Chicago hospitals.  It was further agreed that this project would
            complement Project #10 - A Program for Continuing Education in
            Nephrology - which was recommended for approval by both the site
            visitors and the Committee.
            In recommending approval for the three years requested (in an amount not
            to exceed $150,000 for each of the three years), the Committee further
            recommended the following conditions of approval:
                 1) That the funds be utilized for personnel rather  than  tissue-
                     typing equipment;
                 2)  That the program be expanded to serve multiregional and
                     interregional typing programs;
                 3)  That the budget be reduced from $384,430, $244,984, and $247,177
                     for the first, second, and third year respectively - to $150,000
                     for each of the three years.





            ILLINOIS Regional Medical Program        -4-              RM 00061

            The Co-.nmittee further urged that the Advisory Council establish a
            policy as it relates to RNPS involvement in nephrology and transplanta-
            tion programs.
            Recommendation:  Approval with conditions noted above.
            Direct Costs Only:           lst  Year         2nd Year          3rd Year
                                         $150,000          $150,000          $150,000
            Project #12 - A Pilot ProRram for a Regional Cancer Education Program.
                       The February/March 1970 Review Committee believed this to be
                       a @.qell-conceived program under capable. direction and
            recommended that the proposal be approved in time and amount requested.
            However, March Council recommended that a site visit be  made  to  review
            other proposals in this application and suggested that  the  team  review
            this  rogram during the -visit.
                p
            The Chairman of the site visit team gave a reinforcing report to the
          .Review Committee's original recommendation.  He reported that the inter-
            hospital relationships (Council's primary concern) seemed to be assured
            through the auspices of the North Suburban Association for Health
            Resources, a voluntary association of individuals and institutions
            which serves as an IRMP subregional resource.,  He further reported  that
            the project proposes to demonstrate, on a  pilot  basis,  the  feasibility
            of a regional cancer education program for the State of Illinois.     The
            self-audit type education program is to center around information largely
            supplied by the participating institutions.
            In recommending approval, Committee believed that this program, if
            successful, could lead to the development of similar programs throughout
            the Region.  In line with the site visitors recommendation, the
            Review Committee recommended this as a well-conceived project under
            capable direction and deserving of @ support.
            Recommendation:  Approval in time and amount requested.
            Direct Co     nl             lst  Year        2nd Year (3 months)
                                         $49,155          $12,289
            Doctors Alexander Schmidt  and  George Miller were not present during the
            deliberation of this application.






             ILLINOIS  Regional   Medical   Program      -5-               RM 00061


                                  SUMMARY OF RECOMMENDATIONS


             Project
             Number          Title                    lst  Year     2nd   Year     3rd   Year

              #9         Cofnmunity/University        Non-approval  - revision required
                         Heart and Stroke

                              ram

             #10         A Program for Continuing     $162@257      $181,948       $191,883
                         Education in Nephrology
             #11         Chicago Regional Trans-      $150,000      $150,000       $150,000
                         plantation Program

             #12         A Pilot Program for a        $  49,155     $   12,289     None
                         Regional Cancer
                         Education Program

                                      TOTAL8          $361,412      $344,237       $341,883

             Year                     DIRECT  COSTS   ONLY

              01)                          $361,412
              02)                           344,237
              03)                           341,883
                           TOTAL        $I:,047,532





















                                                              DBM/GRB
                                                              7/6/70






                                    'DRAFT


                                                          A PRIVILEGED COMINICATION
                                                          RM 00061


                                    SITE VISIT REPORT
                            ILLINOIS REGIONAL MEDICAL PROGRAM

                                    June 2-3,  1970


          SITE VISITORS

          John D. Johnson, M.D. (Chairman)
            Chief, Cardiovasc'ular Research Laboratory
            Freedmen's Hospital
            Washington, D.C.
          William Drake, M.D.
            Neurologist
            San Rafael, California
          Frederic Westervelt, M.D.
            Professor of Internal Medicine
            The University of Virginia Medical School
            Charlottesville, Virginia

          STAFF, REGIONAL MEDICAL PROGRAMS  FRRVICE

          -Mr. Charles Heaney, Grants Review Branch
          Mr. Joseph T. Jewell, Grants Review Branch
          Mr. Dale Robertson, Programs Assistance Branch

          ILLINOIS REGIONAL MEDICAL PROGRAM STAFF

        --Morton Creditor, M.D., Executive Director
          Mr. Bryan Lovelace, Jr., Assistant Executive Director
          Patricia R. Brown, R.N., Ph.D., Assistant Director, Allied Health
          Mr. James Wagner, Subregional  Consultant
          Miss Lois Binkley, Planning Associate
          Mrs. Marilyn Leyland, Public Information Assistant
          Mrs. Una Creditor, Grants Manager
          Mr. Joseph Gallagher, Business Administrator
          Mr. Harry Auerbach, Assistant Director of Research
          Sheldon @,laldstein, M.D., Executive Director, North Suburban Association for
            Health Resources (IKIP Subregional Coordinator)
          Mr. L. R. Brosi, Executive Director, Springfield-Central Illinois Health
            Care Planning Council (IRMP Subregional Coordinator)

          MEDICAL SCHOOL COORDINATORS
            The University of Chicago - Ann Lawrence, M.D., Assistant Professor,
                                          Department of Medicine
            Chicago Medical School - Martin Bruetman, M.D., Director, Neurology,
                                       Training Program




            *Dual listing





          ILLINOIS RMP Site Visit               - 2                    RM 00061

          MEDICAL SCHOOL COORDINATORS (Continued)

            university of Illinois - Nat E. Smith, M.D., Associate Dean,
                                       College of Medicine

            Northwestern University -*Jacob Suker, M.D., Assistant Dean,
                                        Postgraduate Education

            Chicago College of Osteopathic Medicine - Paul Vandervort, D.O.

          BOARD OF DIRECTORS'

          William J. Grove, M.D. (Chairman)
            Dean, University of Illinois College of Medicine
          Mr. William J. Silverman (Vice-Chairman)
            Director, Michael Reese Hospital and Medical Center

          REGIONAL ADVISORY GROUP

          Oglesby Paul, M.D., (Chairman, RAG Executive Committee), Head, Department
                                of Medicine, Passavant Memorial Hospital
         *Caesar Portes, M.D., Past Preside-,it, Illinois State Medical Society

          TASK FORCES
            Demography and Economics -*John C. Troxel, M.D., Vice-President, Medical
                                         Director, Blue Cross-Blue Shield
            Manpower.- Randolph Tucker, M.D., Presbyterian-St. luke's Hospital
            Continuing Education - N. Kenneth Furlong, M.D., Medical Director,
                                     Methodist Hospital
            Education   Mr. Don C. Frey, Executive Director, Health Careers Council
                          of Illinois
            Research.- Mr. Louis deboer, Executive Director, Chicago Heart Association
            Evaluation  - *Cecelia Fennessy, R.N., Assistant Professor, University of
                              Illinois School of Nursing


          COMMITTEES

            Heart   Dexter Nelson, M.D., Illinois Heart Association

            Cancer -*Edward F. Scanlon, M.D., Evanston Hospital
                    *Caesar Portes, M.D., Past President, Illinois State Medical
                       Society



                  *Dual listing





           ILLINOIS RMP Site  Visit              - 3                    RM 00061

           COMMITTEES (Continued)

             Subcommittee on Radiation Therapy
               Frank R. Hendrickson, M.D., Director, Radiation  Therapy  Department,
                 Presbyterian-St. Luke's Hospital
               James J. Nickson, M.D., Radiation Therapy Department,  Michael  Reese
                 Hospital
             Nursing - *Cecelia Fennessy, R.N., Assistant Professor,  University  of
                          Illinois School of Nursing


           OTHER PARTICIPANTS
           Albert IN'. Snoke, M.D. (and Pauline Snoke, M.D.) - Coordinator of Health
             Services, State of Illinois
           Mr. James Phillips, Executive Director, Comprehensive  Health  Planning  Inc.,
             Metropolitan Chicago
           Mr. Paul Callagher
           Mr. David M. Kinzer, Executive Director, Illinois Hospital Association
           J. Ernest Breed, M.D., President, Illinois State Medical Society
           Mr. Hiram Sibley, Executive Director, Hospital Planning Council for
             Metropolitan Chicago
           W. Randolph Tucker, M.D., Acting Executive Director, Illinois Health
             Education Commission
           Vernon Forney, D.D.S., Public Health Service Regional  Office,  Chicago,  Ill.

           CONTRACTEES @
          *Mark Lepper, M.D., Presbyterian-St. Luke's Hospital (Hypertension Study)
           Edsel K. Hudson, M.D., University of Illinois (Valley Project)
           George E. Miller, M.D., University  of  I'Ilinois (Educational  Resource  Study)
          *Mr. James W. Wagner, "Mid-South Health Planning Organization"
           PROPOSAL #9 - CO@NITY/UNIVERSTTY HEART AND STROKE PROGRAM
           Leroy Levitt, M.D., Dean, The Chicago Medical School
          *Martin Bruetman, M.D., Chicago Medical School
          *Mr. Louis deboer, Executive Director, Chicago Heart Association
           Marshall Falk, M.D., Medical Director, Fox River Rehabilitation Center
           Edward E. Cordon, M.D., Director of Physical Medicine, Fox River
             Rehabilitation  Center
           Mrs. Mary Ellen  Lavery, R.N., Director, Dept. of Nursing, Fox River
             Rehabilitation  Center
           Israel Light, Ed.D., Dean, School of Related Health Sciences, The Chicago
             Medical School
           Kermit T. Mehlinger, M.D., Acting Project Director, Martin  Luther  King,  Jr.
             Neighborhood Health Center
           Donald Pochyly, M.D., Assoc., Training Section, Center for  Study  of  Medical
             Education, University of Illinois Medical Center
           Maurice A. Schwarts, M.D., Walther Memorial Hospital



             *Dual listing





          ILLINOIS RMP Site Visit                  4 -                 RM 00061

          PROPOSAL #9 - CO@INITY/I'NIVERSITY 'HEART AND STROKE PROCRAM (Continued)

          Reverend William F. Siemers, Administrator, Christ Community Hospital
          Earl N. Silber, M.D., Cottlieb Memorial Hospital
          Sheldon Slodki, M.D., Asst. Coordinator for IRMP, Chicago Medical School

          PROPOSAL #10 - A PROCPAM FOR CONTINUING EDUCATION IN NEPHROLOGY

          Frank A. Carone, M.D., Northwestern University
          Nate Levin, M.D., Northwestern University
          Dr. Meyers, St. Frances Hospital, Peoria, Illinois
          Dr. Morris, Memorial Hospital, Springfield, Illinois
          Hazel Kellams, R.N., Springfield, Illinois
          Mrs. Annie Pope, M.S.W., Veterans'Research Hospital
         *Dr. J. Suker, IRMP Coordinator

          PROPOSAL #11   CHICACO REGIONAL TRANSPLANTATION PROGRAM

          R. Peterson, M.D., The University of Chicago
          Dr. Frank P. Stuart, Assistant Professor, Dept. Surgery, Billings Hospital
          Dr. Warwick Coppleson, Assistant Professor, Department Surgery,
            Wyler Children's Hospital
          Dr. Olga Jonasson, Assistant Prof. Surgery, Illinois Research Hospital
          Dr. Edward Lichter, Prof. Preventive Medicine, Illinois Research Hospital
          Dr. John Bergan, Assoc. Prof. Surgery and Director of Organ Transplantation
            Registry, American College of Surgeons, Northwestern School of Medicine
          Robert C. Muercke, M.D., F.A.C.P., Director, West Side Dialysis Center and
            Director of Medical Education

          PROPOSAL #12 - A PILOT PROGRAM FOR A REGIONAL CANCER EDUCATIONAL PROGRAM

         *E. F. Scanlon, M.D., Evanston Hospital
         *Sheldon Waldstein, M.D., Executive Director, North Suburban Association for
            Health Resources

          PROPOSAL #13 - l@'T ELFARE COUNCIL HEALTH INFORMATION AND REFERRAL PROJECT

          Mr. John Ballard, Welfare Council of Metropolitan Chicago
          Albert Miller, M.D.,(Chairman of Steering Committee)--Michael Reese Hospital
            and Medica  Center
         *J. C. Troxel, M.D., Vice President-Medical Director, Blue Cross-Blue Shield
         *Mark Lepper, M.D., Executive Vice President for Professional and Medical
            Affairs, Presbyterian-St. Luke's Hospital
          Mr. Tom Baab, Executive Vice President, American Cancer Society, Illinois
            Division, Inc.
          Mr. Robert Adams and Miss Gloria Duday, Welfare Council of Metropolitan
            Chicago




          *Dual listing





          .ILLINOIS RMP Site Visit               - 5 -                   RM 00061
          Background on Illinois RMP.  The boundaries of the Region, as in many other
                                       large Regions, are not well-d6fined.  In its
          initial planning grant application, the Region was defined as encompassing
          the State.  As other RMPs have evolved, the Bi-State.RMP (based in St. Louis)

          has claimed the southern half of Illinois as being a part of that Region.
          Likewise to the west, Moline, Rock Island, and other communities of that
          area are considered a part of, and relate to, Davenport, Iowa, for

          medical care.
             The population of Illinois is approximately eleven million., Of this
          total, seven million persons reside in the Metropolitan Chicago Area.
          It was pointed out to the site visitors that this total (seven million) is
          almost equal to the entire population of the country west of the  Mississippi

          River to the California border.
             Five-medical schools and a school of osteopathic medicine are located

          in Chicago.
             The Region contains 70 schools of nursing, 50 schools of medical technology,
          -a,nA 59 x-ray technology facilities. There are 333 hospitals,with a total of
          108,062 beds.  Most of the hospitals are non-Federal.
             There are approximately fourteen thousand medical doctors and approximately

          365 osteopathic physicians within the Illinois Region.
        .,Purposes of the Site Visit.  The site visit was to serve multiple purposes.
                                       Primarily, it was to review four individual
          project requests which were considered during the February/March 1970  review
          cycle   the Council recommended deferral to include a site visit.
             The team was also asked to review a new'proposal - To Establish'a  Unified

          Health Information and Counseling Service   which will be reviewed during

          the June/July 1970 review cycle.






           ILLINOIS RMP Site Visit                6 -                   RM 00061

              Secondly, the team was interested in the Region's concept of the role

           of the Core staff (Dr. Creditor assumed the position of full-time

           Executive Director on the day before the site visit, June 1, 1970).

           They wished to explore the present interrelationships of the Core staff

           with the current Operational projects as well as the degree of  coordination

           of the Core staff with the medical schools.

              The team was interested in hearing a report on four rather large contracts

           which are currently being funded through the Illinois Regional Medical

           Program.

              Finally, the team's mission was to appraise the Region's total program.

           This included progress the Region has made in developing its Regional plan

           since the site visit during June 1969.  The team was especially interested

           in progress which had been accomplished with regard to eight program

           -recommendations made by the June 1969 site visitors. These  recommendations


           were:

              1) that the Regional Advisory Group, boards, task forces, and  committees

                 contain more representatives of minority groups and the lay  consumers

                of service;

              2) that there be a broader distribution of allied health and health

                 manpower involvement in addition to the present nursing profession;

              3) that there be a more realistic relationship established between the

                 Board of Trustees (Directors) and the Regional Advisory Group,

                 pertaining to the review of applications;

              4) that concrete efforts be effected to solve the Upstate versus

                 Downstate cast of the Region;






             ILLINOIS RMP Site Visit                 7 -                 RM 00061

               5) that a more organized, realistic approach be obtained to the

                  collection and collation of data,

               6) that the aims and objectives of contractual arrangements be

                  continually reviewed in relationship to their history, ready

                  availability of any particular information sought, and  the  real,

                  proposed effect on the future of the Region's program-,
               7) that a plan be developed qnd a policy established and agreed
                  upon between agencies and institutions to provide for an auditable
                  accounting procedure for any fees or funds earned in, or as a result

                  of, any project-supported activity; and
               8) that a primary order of business be the appointment and establishment

                  of a Regionwide representative stroke committee.

               In his opening presentation, Dr. Creditor expressed his somewhat
             'awkward position of having to greet a site visit team on his first day

             as full-time Coordinator of IRMP. He then stated some of  his  concerns

             about the existing program and some elements of his strategy to improve it.

               Dr. Creditor agreed with the criticism of the previous site visitors
             that IRMP  was heavily provider-oriented and that this was reflected in the
             physician-dominated Regional Advisory Croup.  He explained that the bylaws
             of the RAG were recently amended to enlarge the membership from 30 to 40,

             and that the new members were to represent other health professions  as


             .well as consumers.
               Another of Dr. Creditor's concerns was the apparent lack of understanding

             of RMP's basic interest on the part of participants in the program.  He
             believed that health interests viewed RMP as just another source of

             federal monies.  He also believed that this is in part illustrated by the

             series of unrelated projects which make up IRMP's operational activity.







            ILLINOIS RNP Site Visit                                        RM  00061

               In developing new dimensions for IRMP, Dr. Creditor's  first  priority

            will be the "reenunciation of subregionalization."  He  envisions  first

            building upon, and then adding to, the three existing subregions  -  the

            North Shore area, the Mid-South section of Chicago, and  the  Springfield

            area (encompassing the central and southern parts of the State).  In this

            effort, he also sees the possibility of working more closely  with  CHP,

            Mental Health, and other agencies whose functioning depends to  a  large

            extent on the delineation of specific areas.

               The new @oordinator's second priority follows naturally from the first,

            and that is to encourage the six medical schools to choose the geographic

            areas for which they want the primary responsibility, and to set new

            directions for these subregions.

               Dr. Creditor is well aware of the problems to be faced in this endeavor

            within the Greater Chicago area itself, since it is here that five of the

            schools are located. As for the rest of the State, he  is  hopeful  that

            the newly established Southern Illinois University Medical School (in

            Carbondale) will contribute to IRNP's outreach into the rural areas of the

            State.

               In terms of overall medical school participation, Dr. Creditor is

            thinking in terms of someone at the associate dean level in  each  school

            to be responsible for IRNP activities.

               Dr. Creditor again emphasized the need to work with CHP and the difficulty

            this agency was having in taking root in most areas of the State.  He

            attributed this to the "A" agency being based in the State Department

            of Health with nothing to which to relate. One result is  that  there  is

            presently only one funded "B" agency in the State (in Chicago).








            ILLINOIS RMP Site Visit                 - 9                     RM  00061


               There appears to be sufficient RMP-CHP cross-participation.  For

            example, Dr. Creditor is a member of the advisory councils for both the

            "A" and "B" agencies, and Dr. Francis Weber,-the   "A" Agency Director, is

            a member of the IRMP Board of Directors.

              More specifically, Dr. Creditor believes it is essential for   IRMP  to

            work with the "B" Agency in Chicago, because, as it stands now, the

            provider-oriented RMP has no visible relevance to the needs of the

            community. To use his words, IRMP needs  to  "develop  legitimacy  within

            its community."  He believes that joint efforts with the consumer-oriented

            CHP group will provide that legitimacy.

              In referring to the Core staff, Dr.  Creditor pointed to a number of

            unbudgeted positions which he would fill with  representatives  of  other

            professions - allied health, computer, and systems  analysis  were  three

            specific areas he mentioned.  He also expressed the desire to cultivate

            Core-type resources outside of the IRMP organization, similar to the

            Educational Support Resource developed by Dr. George Miller (a contractual

            arrangement with the University of Illinois).

              Following Dr. Creditor's opening statements, each member  of  the  Core

            staff gave a brief account of his responsibilities and current activities.

              Mr. Bryan Lovelace, Assistant Executive Director, described his duties as a

            staff representative on three IRMP task forces and his present efforts to

            stimulate interest in health occupations  in the junior colleges.

              New to IPIAP, Patricia Brown, R.N., Ph.D., Assistant Director for Allied

            Health, also has staff duties on several committees and task forces and

            is an active member of a Statewide nursing committee.






             ILLINOIS RMP Site Visit                    10 -                    RM   00061
               Mrs. Marilyn Leyland, Public Information Assistant, outlined the
             beginning of a  more  aggressive  public  relations  program  which  includes

             a new quarterly to be distributed throughout the State.
               Mr. Joseph Gallagher, Business Administrator, is involved in the local
             review of applications to  see  that  they  conform  to  national  guidelines

             and policy statemen ts,
               Mr. James Wagner, Subregional Consultant and first black member of the

             Core staff, is  President  of  the  Mid-South  Health  Planning  Organization,
             a voluntary.organization partially funded by an IRMP contract.  Its purpose
             is to bring together the providers  and  consumers  of  health  care  in  the
             Mid-South area of Chicago in  order  to  determine  community  needs  and  how

             to meet them.

               Miss Lois Binkley,  Planning  Associate,  told  of  her  continuing  efforts
             to ga@her.information on the number and types of health providers, to
             aid her in pursuing  her  primary  interest  -  developing  training  programs

             for health occupations.
               Mr. L. Brosi, IRMP Subregional Coordinator and Executive Director of the
             Springfield-Central  Illinois  Health  Care  Planning  Council,  pledged  his
             continued support as a planning resource for the central areas of the State.
             He also mentioned that since his office and the office of the Director of

             the CHP Agency are located in the same building, there is an opportunity

             for a close working relationship between that agency and IRMP.
               The third Subregional  Coordinator,  Dr.  Sheldon  Waldstein,  is  also  the

             Executive Director of the North Suburban Association for Health Resources,

             a group partly supported by IRMP.  It provides an outreach to the northern
             area of the State and provides IRMP with much valuable planning material.








           ILLINOIS RMP Site Visit                                           RM  00061


             The Medical School Coordinators were next to address the site visit team.


             Dr. Ann Lawrence of the University of Chicago, described her early attempt  s

           to communicate the RMP message to the clinical staff and to develop working

           relationships with the community hospitals.  The initial enthusiasm was

           somewhat dampened when a cytology training program was turned down, but

           it is being engendered again through a new emphasis on community medicine

           and the great strides made by the Mid-South  Health  Planning  Organization

           in making the faculty aware of (and interested in) the health problems

           of the community.

             Dr. Martin Breutman of the Chicago Medical School, viewed his role as a

           buffer between IRMP, the community, and the faculty.  He  stated  that  CMS

           has always worked with and for the community in one  way  or  another.  For

           example  he cited the fact that a large number of CMS graduates have remained

           in Illinois. In speaking of the health  problems  of  the  underprivileged,

           Dr. Breutman referred to the work being done in the black and Puerto Rican

           communities by the Martin Luther King Health Center, which  is  staffed  by

           CMS students and faculty.

             Dr. Nat Smith of the University of Illinois College  of  Medicine,  spoke

           of the close communication between the Medical School Coordinators.  They

           meet weekly and sometimes biweekly to exchange information on the

           activities at their respective institutions.  He believes that these

           gatherings serve as a valuable self-education tool  for  the  coordinators.

           With reference to the University, Dr. Smith mentioned the commitment to

           double the Medical School enrollment within the next  ten  years.  He  also

           .described the Committee on Continuing Education which relied on

           Dr. Ceorge Miller's work, and the Valley project which is aimed at

           ex tending the University into the community,







           ILLINOIS RMP Site Visit                  - 12                       PM   00061

             Dr. Jacob Suker of  Northwestern  University  Medical  School,  spoke  of  a  bi-

           phasic approach to  subregionalization  -  by  first  developing  programs  in

           specific specialty  areas,  and  then  applying  these  programs  through  the

           community hospitals.

             Dr. Paul Vandervort of the Chicago College of Osteopathic Medicine,

           mentioned the free flow  of  information  between  the  coordinators  and  how

           this helped in overcoming the  M.D.-D.O.  barriers.  He  went  on  to  mention  his

           institution's concern with continuing education, allied health tratining,

           and reaching out into  the  community  via  the  establishment  of  storefront

           clinics.


             Following the coordinators, brief sta    tements were made by members of the

           IRMP Board of Directors, Regional Advisory Group, Task Forces, and Special

           Committees.


             Speaking for the Foard  of  Directors  were  its  Chairman,  Dr.  William  Grove,

           Dean of the University of Illinois College of Medicine, and its Vice-Chairman,

           Mr. William Silverman, Director of the Michael Reese Hospital and Medical

           Center.  Both men commented on the action taken by the Board in response

           to the  recommendations  of  the  last  site  visitors.  First,  Board  representa-

           tion has been broadened to include other health professions, nursing,

           pharmacy, dentistry, and hospital administration.  Second, the functional

           responsibilities of the Board  and  the  Regional  Advisory  Group  have  been
           more clearly defined.  The Board is now charged with the overall

           administrative  and  policy-making  responsibilities  of  the  program,  while

           the RAC will concern itself with program development and the review process.

             The Chairman of the Regional Advisory Group, Dr. Oglesby Paul, also
                                                            's                    e,)   7-
           addressed himself to the matters of expanding the RAG membership to







           ILLINOIS PMP Site Visit                   13 -                 RM 00061


           include allied health professions and consumers and to the new role of the

           RAG.  In addition to increasing the membership from thirty to forty, other

           interests are now represented although some difficulty was encountered in

           bringing about the involvement of active consumer participants.  Concerning

           the PAG's expanded role, Dr. Paul stated that the group now considers

           projects that have been turned down by the various regional review

           committees.  This, he says, allows the RAG to become aware of the ideas

           flowing into IRMP and to pursue those which it believes to be important

           to the program.

           Task Force I  Demography and Economics.  Dr. John Troxel expressed the concern

                                                    of this group over the consumer's

           lack of knowledge of available health services throughout the State.

           Accordingly, @ealth resource data is being collected (County by County) with

           the intention of making this information available to the public,  He also

           stated the importance of working with other data-gathering agencies such

           as CHP and the State Department of Health.

           Task Force II - Manpower.  Dr. Randolph Tucker spoke of the activities of

                                     the State-supported Health Education Commission

           of which he is a member.  This body reviews all manpower activities in the

           State and contributes funds to those it believes to be particularly

           meritorious.  It is now in the process of studying the needs for various

           types of health manpower and establishing a central manpower data bank.

           Task Force III - Continuing Education.  Dr. Kenneth Furlong reported on the

                                                  activities of this group, which

           reviews the continuing education components of all proposals submitted to

           IRMP.  He is working with Dr. Ceorge Miller to facilitate the advancement

           of continuing education activities in the State.  The task force is also


           wnrlcincy t-@.qrti ily%c,-rnelin(y f-Iim 14@@n@,, o@A        @l,@--A 1,@,








           ILLINOIS RMP Site Visit                - 14 -                 RM 00061


           the medical schools and the outlying hospitals.

           Task Force IV   Education.  Mr. Donald Frey described this group's activities

                                       in encouraging proposals dealing with

           regionalizing education, upgrading the quality of care, and collecting

           information useful in manpower planning.

           Task Force V - Research. Mr. Louis deboer, the newly-appointed  Chairman,

                                    reported that this group has had the basic

           responsibility for reviewing the research components of proposals.

           Dr. Creditor pointed out the inactivity of this task force and questioned

           the need for its existence.


           Task Force VI - Evaluation.  Miss Cecelia Fennessy, R.N., told the site

                                       visit team that this group has not met during

           the past year due to the lack of project activity.  She also pointed out
           that tl;is group did not become involved in the evaluation aspects of proposals

           because they generally have their own built-in evaluative mechanisms.

           Heart Committee.  Dr. Dexter Nelson reported on this committee's work in

                            setting priorities for coronary care in the  Region.  It

           conducts special studies on resources available and makes decisions as to

           what is needed.


           .Cancer Committee.  Dr. Edward Scanlon commented that the regional priorities

                             for dealing with the problems of cancer ate:  1) education

           of professionals; 2) detection; and 3) treatment.

            During a luncheon meeting, the site visit team was addressed by representa-

           tives from various State and voluntary organizations.

            The first to speak was Dr. Albert Snoke, Governor Oglesby's  Coordinator

           for Health Services. Dr. Snoke declared that the Governor placed a high

           priority on health and health planning.  In.line with this, Dr. Snoke felt








           ILLINOIS PMP Site Visit                  - 15 -               RM 00061


           it was imperative that RMP and CHP work together, recognizing that at the

           present time, CHP is playing a somewhat minor role in the State. As  for

           RMP itself, he is dissatisfied with the categorical limitations and the

           control of the program by the medical school deans.  'He concluded by saying

           that power politics should be kept out of health planning, that manpower

           activities must be coordinated, and that there is a necessity for working

           together in times of funding shortages.

            Dr. Snoke was followed by Mr. James Phillips, Executive Director of

           Comprehensive Health Planning, Inc. - Metropolitan Chicago, who held the

           opposing view that both RMP and CHP are inextricably involved in politics

           and that this constitutes the major reason why CHP has failed to take a

           firm hold in the State.


            The next to speak was Mr. David Kinzer, Executive Director of the

           Illinois Hospital Association.  The IHA represents th ree hundred hospitals,

           and, according to Mr. Kinzer, the primary concern has been the lack of

           coordination among approximately forty planning bodies in the Region.  He

           sees RMP, with its emphasis on cooperative arrangements, as a tool to

           remedy this situation.

            Dr. Randolph Tucker, Acting Executive Director of the Illinois 1.4ealth

           Education Commission, made his second appearance before the site visit team,

           to talk about the other major activity of the Commission, in addition to

           manpower as mentioned earlier.  This group has at its disposal $14,000,000

           for grants to medical schools, to increase their enrollment.  At this time

           there is a commitment to double enrollment by 1980.






           ILLINOIS BMP Site Visit                 - 16 -                  RM   00061

           Ceneral Observations.  The site visitors were favorably impressed by

                                   Dr. Creditor's insight regarding the problems of both

           the organization and the Region which it,is intended to serve.  The

           preliminary plans and priorities he has developed to cope with this situation

           give   evidence of a strong fundamental grasp of the RMP concept.

             As for the recommendations of the last site visitors, all but one have

           been satisfactorily implemented - the exception being the establishment

           of a regional stroke committee. Dr.  Creditor  assured  the  team  that  a

           stroke committee was being developed and that he would do all he could to

           expedite its establishment.

             There were several criticisms, foremost of which was that IRMP has been,

           and still is, a Chicago program with little or no contact with the rural

           areas of the State.  Changing this pattern, however, seems to be

           Dr. Creditor's first priority.  Also noted was an inherent over-

           organization in the IRMP which was reflected  in  some  of  the  projects.

           Another shortcoming was the apparent overdependence on data collection.

           Although gathering information is critical to planning, the site visitors

           believed that the various task forces and committees should also spend

           time talking with people in the  communities  which  are  being  surveyed.
           This would serve the twofold purpose of  giving  RMP  visibility  and,  at
           the same time, serve.as a test of the validity of  the  data  -  that  is,
           do the needs deduced from the data coinci-de with the needs as expressed

           by consumers?
           Contracts.  The site visit team was asked to review the progress of four

                        contracts undertaken by IRMP:

                        1) Control of Hypertension in Selected Illinois  Communities:
                           Urban, Suburban, Rural - Dr. Mark Lepper, Presbyterian-

                           St. Luke's Hospital.







            ILLINOIS RMP Site Visit                    17 -                  RM 00061


            Contracts (Continued).

                    2) The Valley Project - Dr. Edsel  Hudson, University of Illinois.

                    3) Educational Support Resource -  Dr. George Miller, University


                       of Illinois.


                    4) Mid-South Health Planning Organization    Mr. James Wagner.

             By and large, the site visitors were well satisfied with the progress

            of these activities, especially with the Valle y and Mid-South Projects

            because of their direct outreach into the more needy segments of the

            community.  Dr. Miller's Educational Resource Project has been mentioned

            several times in this report in relation to both the IRMP program and

            projects.  The site visit team was genuinely impressed with the many

            facets of this most valuable activity.

             There were some concerns over the Hypertension Study - concerns over

            elements of the research methodology, provisions for followup and treatment,

            and the need to relate it to stroke planning.  It was pointed out, however,

            that this was an earmarked project, rather hurriedly developed, and that,

            in general, stroke was one of the Region's weak areas.

            Projects.

            lt9 - Community/University Heart and Stroke Program.  Although impressed by

                                                                  the substantial efforts


            of many people that went into the planning of this proposal, the site visit

            team had sufficient concerns to preclude its approval.  While recognizing

            the possible benefits and economies of sharing personnel, the reviewers

            felt that the current central administrative setup was too complex to

            'function effectively and that this program might better be presented as

            two separate proposals.






          ILLIliOIS Pd4P Site Visit                18 -                     RM 00061

            The team also felt that some consideration should be given to involving

          areas outside of Cl-licago, at least in the training aspEcts.  The  people

          who need help the most are often those in the remote communities, and

          there can be no regional program without provision for  these  smaller  areas.

            The reviewers were also dissatisfied with the  diagnostic  screening  aspect

          of the proposal.  If prevention and detection are objectives, then reason

          would dictate a larger screening component.  Yet the only screening proposed

          would take place at the Martin Luther TTing Tiealth Center, and even  this

          has been inadequately planned.

            Finally, the evaluation component (especially for  the  stroke  program)

          has not @,een clearl%l defined.


          Recommendation:  Nonapproval - revision required.

          Project #10 - A Program for Continuing Education i@- "7epl-irolo@v.

                        The reviewers were well satisfied with  the  statement  prepared

          by the project proposers in response to the issues raised by  the  March  1970

          Review Committee.


            With regard to funding for future years, the applicants alluded to State

          and Federal interests in renal disease as well as some private sources

          (Kidney Foundation and Illinois Ileart Association), and tuition.

            Plans were also mentioned to develop an educational program aimed at

          producing a "renal health nurse" who will be trained in  aspects  of  both

          prevention and treatment of renal disease.

            In speaking of the criticism that the program  seemed  heavily  oriented

          to the dialysis procedure, the applicants pointed out that this was a

          comprehensive training and continuing education approach and did not restrict

          itself to dialysis.






          ILLINOIS  RMP  Site  Visit                - 19                     RM 00061

            Although  not   feasible on a Statewide !,,asis, the proposers  felt  that  it

          would  be  reasonable  and entirely within the scope of the project, to set up

          a model comprehensive care program in one area,- preferably Springfield,

          since a specialized unit  with  full-time  personnel  and  good  facilities  is

          presently in operation there.

            With respect to the role of the  University  -  in  addition  to  its  duties

          as fiscal agent, it will   contribute in terms of faculty, standard facilities,

          and special facilities such as electron microscopy, tissue culture, a renal

          biopsy library, fluorescence microscopy, specialized microbiologic techniques,

          and others.

            As for the definitions asked for (nurse, technician, and physician trainee),

          none of these categories would include individuals engaged in a formal

          training program.  "Nurse" refers to a nurse at any level who is given

          specialized instructions in the field of renal disease.  "Technician" refers

          to an individual trained in the laboratory aspects of renal care.  "Physician

          trai.nee" refers to a physician who has completed the internship and

          residency training that he intends to have.  He would be engaged in the

          clinical or laboratory  practice  of  medicine  before  entering  the  program.

            The site visit team posed a question of its own as to whether or not there

          should be a direct linkage with Project #11, a Renal Transplantation Program.

          It was decided that such a relationship would develop of necessity as

          shared interests and experiences brought the two groups together, and

          that it would not be imperative to  impose  such  a  condition  at  this  time.

          .Recommendation:  Approval in time and amount requested.

                            Ist  Yr.      Pnd Yr.       3rd Yr.

                            $162,257      $181,948      $191,883




           ILLINOIS RMP Site Visit                      20  -                     RM  00061

           Project #11 - Chicago Regional Transplantation Program.  The site visit team

                          viewed this proposal favorably  both  in  terms  of  its  growing

           role in the treatment of renal disease and regional implications, but felt that

           the price tag was much too high, especially since this project is already ongoing.
             For the past several years, four medical schools have operated through
           eight medical centers in  Chicago  in  carrying  on  a  limited  transplantation
           program.  RMP funds are being sought to expand this program due to increasing

           demand and more sophisticated technology.

             The team believed that the prime factor  in  the  high  cost  of  the  project

           was the procurement of good kidneys.  Currently it is costing roughly
           $8,000 per kidney although other experience indicates that the same job

           can be done for one-quarter of that amount.  The reviewers felt that the
                        J-

           very strict scientific standards of acceptability are resulting in the loss

           of many usable kidneys and hence the enormous cost per kidney.
             It was believed that a  natural  rapport  would  evolve  between  Project  #10

           (above) and this project, due to the'interrelationships of the purposes

           and-objectives.
             In recommending  approval  for  the  three  year.s requested (in an amount not
           to exceed $150,000 for each of the three years), the site visitors recommended

           the following conditions of approval:  1) that the funds be utilized for
           personnel rather than tissue-typing equipment; 2) that the program be expanded
           to serve multiregional and interregional typing programs; and 3) that the budget
           be reduced from $384,430, $244,984,  and  $247,177  -  for  the  first,  second,

           and third year respectively - to $150,000 for each of the three years.
           Recommendation:  Approval for three years, at a reduced amount.
                             Ist Year            2nd Year           3rd Year

                             $150,000            $150,000,          $150,000








           ILLINOIS RMP Site Visit                                        RM 00061

           Project #12 - A Pilot Program for a Regional Cancer Educational  Program.

                         This project had been approved by the February 1970  Review

           Committee, but the March Council requested that the site visitors include

           it in looking over the entire Illinois package.  The interhospital

           relationships (Council's primary concern), seem to be assured through the

           activities of the North Suburban Association for Health Resources, a

           voluntary association of individuals and institutions which serves as  an

           IRMP subregional resource.

             The project proposes to demonstrate, on a pilot basis, the  feasibility

           of a regional cancer education program for the State of Illinois.  This

           self-audit type education program will center around information  largely

           supplied by the participating institutions.  It appears reasonable to

           assume that this program, if successful, could lead to the development of

           similar programs throughout the State.

             The site visitors agreed with the Committee that this is a  well-conceived

           project, under capable direction, and is deserving of RMP support.

           Recommendation:  Approval for time and amount requested.

                            lst Year               Second Year (3 monthsi

                            $49,155                $12,289

           Project #13   Unified Health Information, Referral, and Counseling Service -

                        Welfare Council of Metropolitan Chicago.  The reviewers were

           enthusiastic about this project and felt that it was very much needed.  They

           observed with satisfaction that the program paid attention to both  regional

           and subregional considerations.

            The initial parts of the program appeared very complex, and the  team  felt

           that some phasing-in time would be needed while the project gained momentum.

           The proposers contended that they could, with the people they had on  board,








           ILLINOIS @IP Site Visit                    22 -                 RM 00061


             The team also perceived a need for a clearer justification of the personnel

           budget.  Several questions were raised regarding the rather expensive

           provision for consultants and the roles to be played by such people as  a.

           social psychologist, a medical sociologist, and a consulting physician.

             Another concern was support for future years.  Although other similar

           projects had fared rather successfully in this regard, the team felt  that

           there should be a financial feasibility study, preferably by the end of

           the second year. In this connection, the reviewers felt that  the  Welfare

           Council should show some evidence of its own involvement in terms of


           financial support.

            The team felt that the funding level for this project should  not  exceed

           $1,000,000 (total costs) for the three years - about a thirty percent

           reduction each year.

           Recomme'ndation:  Approval in reduced amounts for three years, contingent

                           upon clarification of the following issues:  detailed

           budget; personnel justification; Welfare Council financial involvement

           and contribution; support for future years; subcontract activities;

           and hardware.


            lst Year       Pnd Year       3rd Year        (Direct Costs)

            $226,000       $317,000       $363,000







          ILLINOIS RMP SITE VISIT                  23 -                        RM 00061


          SU@RY OF SITE VISITORS' RECOT@IENDA-TIONS ON OPERATIONAL PROPOSALS DEFERRED


                              FOR SITE VISIT BY @IARCH 1970 COIIINICIL


          PROJECT
          NUMBER  TITLE                                     RECOMMENDATION


                                                            lst Yr.   2nd Yr.     3rd Yr.
                                                                    (Direct Costs)

           9       Community/t'niversitv Feart and            Nonapproval ---- Revision
                   @troke Program                                 Required
          10       A Program for Continuing @ducation
                   in Nephrology                            $169,257  $181,948   $191,883

          11       Chicago Regio,ial Transplantation
                   Progrhm                                  $150,000  $150,000   $150,000

          12       A Pilot Program for a Reizional Cancer
                   Educational Program                      $ 49,155   $12,289






          APPLICATION ST,BMITTED FOR JU,NE/JULY REVIEW  CYCLE


          PROJECT
          NUMBER   TITLE                                    RECONENDAT ION


                                                            lst Yr.   2nd Yr.     3rd Yr.
                                                                  (Direct @osts)

          13       Unified Health Information, Referral,
                   and Counseling Service   T4elfare
                   Council of Metropolitan Chicago          $226,000  $317,000    $363,000





           ILLII\'OIS RMP SITE VISIT                   - 24 -                        RM    00061
                  SITMARY OF FUNDS REQUESTED BY APPLICANT     AND FUNDS RECOMMENDED
                                          BY SITE VISIT TEAM
           PROJECT                     AMOUNTS REQUESTED             AMOUNTS RECOMENDED
          NU@IBER TITLE               (DIRECT COSTS)                 (DIRECT COSTS)
                                       lst Yr.  7nd Yr.    3rd Yr.   lst Yr.  7nd Yr.  3rd Yr.
           10   Continuing Education
                in Nephrology-        $162,257  181,948    191,883   162,?5@  181,948  191,883
                TOTAL #10 -  3  Yr.  request  =  $536,088            TOTAL  #10  -   Recommended
                                                                     for 3 Yrs. = $536,088
          11    Chicago Regional
                Transplantation
                Program                384,430  244,984  247,177  150,000  150,000  150,000
                TOTAL #11 -  3  Yr.  request  =  $876,591            TOTAL  #11  -   Recommended
                                                                     for 3 Yrs. = $450,000
          12    A Pilot Program  for                   -
                Regional Cancer
                Educational Program     49,155    12,289              49,155    12,289
                TOTAL #12 - lk Yr. request        $61,444            TOTAL  #12  -   Recommended
                                                                     for lk Yrs. = $61,444
          13    Unffied Health
                Information,
                Referral, and
                Counseling Service     323,493  452,833  518,821     226,000  317,000  363,000
                'TOTAL #13   3 Yr. request    $1,295,147             TOTAL  #13  -   Recommended
                                                                     for 3 Yrs. = $906,000



                                                                   $587,412  661,737  704,&83
                                                                     (TOTALS RECOMMENDED)















                                                                                        6/22/70


















            0                                                              0                                                              0













                               REGIONAL MEDICAL PROGRAMS SERVICE
                   SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                 (A Privileged Communication)



            INDIANA REGIONAL MEDICAL PROGRAM
            Indiana University School of                          RM  0043 7/70.1
            Medicine                                              June 1970 Review Committee
            1300 West Michigan Street
            Indianapolis, Indiana   46202

            PROGRAM COORDINATOR:  Robert B. Stonehill, M.D.


            Requested
            Program
            Period              lst Year         2nd Year         3rd Year         Ti-)tal-
            Direct Costs        $82,534          $65,587          $69,953          $218,074
            Indirect Costs       17,969           19,400           20,952            58,321

            Total               $100,503         $84,987          $90,905          $276,395


               tor :  The Region received its first planning grant($295,500 d.c.o.)
                      on January 1, 1967 and an 02 planning award($491,479 d.c.L).)
            on January 1, 1968.
            In September 1968, a site visit was made  in  order  to  determine  IRMP
            readiness for operational status.  The visitors commented on the
            Regions strong leadership, community involvement, and good working
            relationship with the University, and therefore, strongly recommended
            approval of Indiana's operational application.     The November 1968
            Council agreed and an operational award  ($1,363,571  d.c.o.)  was  made
            on January 1, 1969 including support for core, two operational pro-
            jects and two feasibility studies.
            An amended 02 continuation award ($1,513,690 d.c.o.) was issued for
            the period beginning January 1. 1970.  This award included support for
            core and ten projects.
            A listing of current projects status follows the description of the
            present application.
            Present Application: This is a request for thre@ year support of
                                  two new operational projects.




              Indiana                            -2-                     RM 00043  7/70.1
              Proj'6ct #19                           ling to the Indiana Recion    Requested
                                                     ject is the development       First Yezir
              o f 4fi efficient computerized system for the recognition of genetic  $28,910
              disease by pedigree linkage.
              A secondary objective is the provision of initial instruction and  remedial
              education in medical genetics to physicians on a state-wide basis  by
              lectures and through the use of video tape on the Indiana Higher  Education
              Telecommunications System (IHETS).
              At the Indiana University School of Medicine, genetic  counseling  is
              currently being done by the Department of Medical Genetics which grew.out
              a training program initiated in 1961.  During the past nine years.
              3,000.'families have been seen in the Medical and Dental Genetics clinics
              and data have been obtained on 150,000 individuals in these families.
              All family data are punched on IBM cards for easy retrieval, sorting
              and analysis.  Available equipment includes an IBM 7040 computer PDP-8
              Analog to Digital converter. Calcomp XY plotter, disc  storage  unit,
              an@l         'e-leyp,-inch and sorting equipment.
              In the belief that it has established a sound organizational framework
            ..for genetic counseling,the Region is proposing several activities to be
              included in this project.
              The first is a Genetic Counseling Clinic which will meet weekly.  Once
              a family is referred by a private physician, a ward physician in one
              of the local teaching hospitals or a private or government agency of
              some. type, it is the responsibility of  the  genetics  fieldworker  to
              make contact with the family, obtain a pedigree, and make an appoint-
              ment',for the patient and relcvant family members to be seen  at  the
              clinic.  Graduate students will play an active part in obtaining pedi-
              gree information and performing appropriate  diagnostic  tests.  This
              expanded clinic is based on an estimated 2,000 visits  this  year  as
              compared to only 60,five years ago and 1,011 last year.
              A second activity will be the carrying out of population  studies  in
              two main areas, empirical risk data, and pedigree linkage.  The former
              concerns the actual routine collection of data.  Following completion
              of the diagnostic evaluation, the information obtained by the field-
              worker and from the laboratory tests is fed into the computer.    The
              ultimate goal is to permit a rapid, accurate, and continual updating
              of the accumulated experience of the counseling center  with  respect
              to each type of problem.  The other type of population study, pedigree
              linkage, is designed so that new patients with specific genetic diseases
              may be linked genealogically by computer techniques to other families
              with identical d@eases in a master file.
              The third component of the proposal is the addition and expansion of
              certain screening and diagnostic  proceedures.  These  center  around
              cytogenetics and biochemical studies.  The Dresent cytogenetics labor-
              tory provides routiro'karyotyping, autoradiography and meiotic studies,
              and various cytochemical studies of metabolic defects in tissue ctil-
              ture, but the number of tests that can be performed is limited  because  of







            Indiana RMP                        -3-                         PM 00043 7/70.1


            insufficient lab space.  It is anticipated that both lab space and
            personnel will have to double in order to  meet  the  rising  demand  for
            services. As for the biochemical  studies,  there  is  a  proposed  addition
            of an amino acid laboratory, an enzyme  laboratory  and  an  electro  micro-
            scopy laboratory, plus the expanding of the existing geneotyping, immunology,
            and lipid chemistry  a oratories.

            There is also a research aspect  in  the  proposed  project.  The  sponsors
            contend that the new medical  genetics  counseling  center  would  provide
            opportunities for research into areas such  as  twin  studies,  centroniere
            napping cytoplasmic inheritance, chromosome breakage syndrome,,;, and
            polymorphic markergenes.

            Since one of the projects major goals is  the  production  of  a  computer
            program, the evaluation seems straightforward,  i.e.,  the  existence  of  a
            working computer program accompanied  by  a  verbal  narrative  concerning
            the types of operations and  the  information  they  contain.  The  program
            can also be evaluated by counting (a) the  number  of  searches  made  and
            (b) the number of  successful pedigree linkages.


            Second Year:     $31,467                            Third Year:     $34,4t4


                                                                            Requested
                                                                            First   Year
            Lr   ct #20 - Training Programs for Respiratory Care               $53,624
                           Technicians
            This request proposes a respiratory  care  training  program  for
            selected "technicians" from nine institutions  in  the  state  of
            Indiana, this number to be increased as the program develops.  The
            training consists of both theoretical and practical teaching for
            varying periods of time (I or 2 months) depending on tl)e students
            level of competence.  At the completion of the course, these "tech-
            nicians" are to return to their hospitals  to  resume  their  duties  and
            to cooperate in the expansion of the  local  teaching  and  patient  care
            activities. They would assist physicians  in  the  care  of  patients  with
            acute or chronic respiratory disorders, assuming,  within  the  -limits  of
            their capabilities, more  primary  responsibility  for  such  care.  Thev
            imuld participate in setting up and/or expanding  the  operation  of  the
            local facilities, and in training other  local  paramedical  personnel-  in
            order to augment such staff in the existing or proposed specialized
            facilities.  The benefits of this program should be marked by a decrease
            in morbidity and mortality for  patients  with  respiratory  disorders,  the
            return of a significant number of  these  patients  to  productive  life,
            and a reduction in  hospitalization  costs  (individual,  state,  federal)
            through optimal in-patient and out-patient  care  and  the  prevention  of
            complications.

            Candidates will be selected by the  physicians  heading  the  program  at
            each of the participating institutions.  Those selected must be a
            paramedical employee at his institution and  must  have  some  expertise  in






             Indiana RMP                     -4-                     RM 00043 7/70.1


             one or more of the three areas of respiratory service:  pulmonary
             function laboratory, rehabilitation, or intensive care.  On the basis of
             their experience prior to entering the program and the competence gained
             during it, the trainees are expected to perform routine pulmonary
             function, to have practical experience in handling of respiratory emer-
             gencies, to understand the principles of mechanical therapy as applied to
             chest patients, and to be familiar with the equipment routinely used in
             the care of patients with respiratory disorders.

             Evaluation will consist of written tests before and after the course
             plus appraisal of on-the-job performance by the immediate supervisor
             and the program directors.


             Second Year:   $34,120                      Third Year:    $35,539






                 Indiana RMP                             -5-                        RM 00043 7/70.1


                                          ONGOING OPERATIONAL PROJECTS


                                                (Direct Cost Only)



                 Project                          Current Budget         Carryover              Date
                 and Title                     Including Carryover          Included         Initiated

                    Core                               $460,967              $13,556

              #2  - Multiphasic
                    Screening -
                    Flanner    House                  265,000               40,000              I/l/69

              #3  - Regional    Stroke
                    Program                           281,241                 -0-               I/l/69

              #4  - Network  of   Cor-
                    onary Care Units                  157,250               25,000              1/l/69

              #5  - Health    Manpower
                    Recuitment                         25,000               25,000              I/l/70

              #6  - Education    and
                    Practice of
                    Prospective Medicine               20,734               16,225              I/l/70

              #9  - Community Health
                    Centers - Metro-
                    politan Health Council            169,550               19,550              1/l/69

             #11  - System of Continuing
                    Nurse    Education                 51,450               20,450              1/1170

             #13  - Educational Program
                    for CCU Nurses                     40,428               40,428              I/l/70

             #14  - Medical    Library
                    Extension Service                  26,197               26,197              I/l/70

             #16  - Detecti,z)n  and
                    Management    of
                    Chronic Pulmonary
                    Disease                            15,873               15,873              I/l/70

                    TOTAL                            $1,513,690             $242,279






                                                                   RM 00043  7/70.1
                .na RMP                         -6-




                                   APPROVED   UNFUNDED PROJECTS



                ect

            #15   Fetal Cardiovascular
                  Monitoring for Optimal
                  Patient Care                         12/69               $35,264


            #18   Cooperative Arrangements
                  for Community Coronary
                  Care Program   Northwest
                  Indiana                               3/70               $41,966






                                                                         II\IDII@A
            STAFF OBSERVI'I'IONS                                         R@l 000/i3 7/70.1


             Project #1.9
                            At its I)cc(,jiil)o)- 1969, iii(-,eti'-ng, the, 'N',,ttionil Advi.sory
             Council-, after revj-e%.7iilg special- i.i-ifoi@-riiatioi-i obtained by the staff at
             the request of the August Council-, disapproved @l  i)@olect  that  would
             establish a medical genetics cl-iiiic.   As a letter o@/?pol@l-cy, the
             Council- stated. that, ". . . tlii-s project proposes @lie  demonstration
             of technique which has not yet: been developed to the extent that it is
             of primary importance in patient care and one which is not sufficiently
             reIE"7--i-,-@ to the problems of the categorical di8eas es. In recognition
             of the continuing basic resc@a.i--cl) and clinical investigation of  this
             technique, the Council- has agreed to reconsider, two  years  f.ron  now,
             its applicability to direct patient caret@










































                                                                                          5 2 2






                                                               A PRIVILEGED COMMUNICATION



                                  SUMMARY OF REVIEW AND CONCLUSION OF
                                      JUNE 1970 REVIEW CO@@MITTEE


                                   INDIANA REGIONAL MEDICAL PROGRAM
                                           RM        7/70.1


                          FOR CONSIDERATION BY JULY   1970 ADVISORY COUNCIL


             Project Y@19  Delivery of Genetic  Counceli@@a t e Indiana Re 1 ii

             Critique: This proposal was not considered by the  Committee  due  to  a
                       decision of- the December 1969 National tdvi.sory  Council  to
             withhold funding of such projects for two  years  pending  the  findings
             of further basic  research and clinical investigation into the appli@
             lability of genetic counseling to direct patient care.

             Recommendation: Non-approval I - no P14P funds recommended.


             Project #20 - Training Programs for Res)iratory Care Technicians
             Lritiae: The Review Committee was generally dissatisfied
                       proposal.  The reviewers felt that the project was pool--Iy
             described; the curriculum was not clearly defined nor was much ati-on-
             tion given to follow-up and evaluation of performance.  'There  wei-e  also
             some concerns over who would be giving the instrti('-,tionatid i@@7'Lliit would
             be the exact duties of the graduates upon returning to their institutions.
             Question was also raised as to the appropriateness of leaving the deter,-.,
             mination of educational qualifications up to the various institutions.
             This concerned the reviewers since the project intends to coLibi@-e
             tlieor tical concepts with direct patient care.
             Throughout its deliberations, the Committee was concerned over the
             increasing number of categories in the allied health field and the
             possible effect of further  fractionalizing  health  care  delivery.  As
             for this particular proposal, the reviewers wondered  why  there  had  been
             no mention made of any relationship  with  established  inhalation  therapy
             programs and what indeed were the need for separating seemingly  ii.,ko.
             functions. Along these lines, it was  suggested  that  contact  be  made
             with the newly formed Committee on Emerging  Professions  of  the  American
             Medical Association.

             The Committee thought that this proposal might be resubmitted as a pilot,
             project to determine the need for such a training program  and  if  so,  to
            .develop an appropriate protocol and curriculum.

             Reconimendatio!il:  Non-approval 11 -returti.for revision




                                                                     INDIANA RMP
                                                                     00043 7/70.1







                                   SUMMARY OF FUNDING RECOI@ZIENIDATIONS


             Lr-o@Ct                 01-Year           02-Year          03-Year         Total
             (#19-Requested)        ($28,910)          ($31,467)     ($34,414)        ($94,791)
              #19-Recoinmended         -0-                -On            -0-             -0-

             (#20-Reque@ted         ( 53,624)          ( 34,120)        35,539)
              #20-Reconimended         -0-                -0-           -0-             -0-



             (Total. Requested)     ($82,534)          ($65,587)     ($69,953)       ($218,074)
             Total Recommended         -0-                -0-           -0-             -0-

























                                                                      RMPS/GRB/7/6/70

















            0                                                              0                                                              0




                                                                  (A Privileged Conmunication)



                                  REGIONAL  MEDICAL  PROGRAMS  SERVICE
                        SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION


               INTERMOUNTAIN REGIONAL                                 RM 00015 7/70.1
                 MEDICAL PROGRAM                                      June 1970
               University  of  Utah                                   Review   Committee
               University  and  2nd South Streets
               Salt Lake City, Utah  84112

               Program Coordinator:  C. Hilmon Castle, M.D.

               Requested
               Program
               Period             lst Year      2nd Year      3rd  Year     Total

               Direct Costs       $72,267       $70,426        $74,533       $217,226
               Indirect Costs      17,884        19,672         21,640         59,196


               TOTAL              $90,151       $90,098        $96,173       $276,422

               History:  The Region initiated   its third operational  year  with  an
                          amended award, effective April 1, 1969,  in  the  direct  cost
               amount of $2,407,622. Of  the  $2,407,622  direct  cost  level,  $2,142,788
               was financed with new funds and $264,834 by funds unexpended from prior
               grant periods.

               A site visit team evaluated a request for renewal of seven ongoing
               operational projects and one revised  renal  disease  project  on  October
               28, 29 and 30, with a resultant  recommendation  of  approval  for  three
               additional years in the direct cost amount of $2,064,229 for the
               programs fifth year  of  operations.  In  addition,  the  team  recommended
               funding of the renal disease program  in  the  amount  of  $94,685.  These
               recommendations were endorsed and concurred  in  by  the  Review  Committee
               and the National Advisory  Council.  This  project  is  awaiting  funding
               from FY 1970.

               The Region was advised on January 15, 1970,of  an  impending  grant  to  be
               awarded for the continuation of the  components  covered  by  the  renewal
               application and the one project supplement (approved as referred to
               above) in the amount of  $1,781,097.  Council  committed  support  for  the
               balance of the ongoing program's fourth  year  is  $348,641,  which  brings
               the Region's funding level to the direct cost amount of $2,129,738.
               This amount will support seventeen ongoing  projects,  two  of  which  the
               Region is terminating March 31, 1970.

               The proposal for a Multiphasic Screening  Program,  Project  #26,  in  the
               314(e) approved Neighborhood Health Center in  Salt  Lake  City  was  the
               subject of a site visit on March 25, 1970  and  was  presented  to  Council
               immediately thereafter. It was approved  in  a  revised  form  which  was
               prepared in line with the critique of the Review Committee and the site
               visitors.  This project is earmarked for funds from FY 1971.





          INTERMOUNTAIN RMP                   -2-                    RM 00015 7/70.1


          PROJECT                                       STATUS
          1-Training Feedback Seminars                  Now merged with  Core
          2-Network for Continuing Education            Renewal - 12/69.1
          3-Comunications & Information Exchange        Now merged with  Core
          4-CPR Training                                Region terminating 3/31/70
          5-CCU Training - M.D.s                        Renewal - 12/69.1
          6-Training for R.N.s                             11        it
          7-Clinical Cardiology Training                             It
          8-Community Cardiovascular                                 It
          10-Computer-Based Monitoring System                        it
          11-Cancer Training                                         it
          13-Stroke & Related                           Funded until 3/31/70
          14-Respiratory Therapy Program                   it    11    It
          16-Endocrine Metabolic Laboratory                it    It  3/31/71
          17-CCU - Small Hospitals                      Region terminating 3/31/70
          18-Model Stroke Care & Rehabilitation         Funded until  3/31/71
          19-Core Adminis. Planning & Eval.             Renewal - 12/69.1
          20-Radiological Capability                    Approved (May Council) as yet unfunded
          21-Myocardial Infarction Data Systems         Approved (Feb. Council) funded from
                                                          carryover for one year only (3/31/70)
          22-Renal Disease                              2/69.2 - revised project newly
                                                          submitted as #25 12/69.2
          23-Biomedical Information                     2/69.1 - retu=ed for revision
          24-Hypertension                               2/69.1 - returned for revision
          25-Renal Disease                              Approved (Dec. Council) -.waiting award
          26-Multiphasic Screening                      Approved (March Council) as yet unfunded
          Project #27 - Head, Neck and Oral Cancer Detection Tta@n .        lst Year
                       This project builds on a feasibility study made      $72,267
          in April 1968 in Carbon County, Utah, in a community of
          16,200 people.  With cooperation from the State and local
          medical and dental associations, the Utah Division of the
          American Cancer Society, community leaders, hospital officials,
          church organizations and the Utah State Division of Health, a head,
          neck and oral cancer detection program was undertaken in  the  City
          of Price.
          Five of the conmunity's seven physicians and three of its four dentists
          participated for two days and helped examine 1,400 people at a public
          clinic in the College of Eastern Utah.  Procedures consisted of visual
          examinations of the skin of the head and neck, palpation of cervical lymph
          nodes and thyroid, intraoral examination and  palpation, intrapharyngeal
          examination and indirect laryngoscopy if the patient complained of hoarseness.
          Of the 1,400 screened persons, 354 exhibited lesions suspicious enough to
          warrant further investigation through Pap smear and/or biopsies.




              INTERMOUNTAIN RMP                 -3-                  RM 00015  7/70.1

              The present proposa'L is designed for training in early detection and will
              reach 75% of the Re'gion's physicians and dentists.  Over a three-year
              period 36 programs (one each month) will be held in 36 individual communities
              in six states  These will consist of a teaching session in signs, symptoms
              and technique; of diagnosis, followed by a clinic at which approximately
              500 people will be screened.  This will provide a supervised, practical
              experience where the physicians and dentists can apply what they have
              learned.
              Support is requested for a maximum of 36 months. The teaching  team  is
              available and a curriculum has been established.  Within six weeks of
              approval the first program can be held.  Arrangements have already been
              made for pathological interpretations of the histological and cytological
              specimens.
              The project provides for professional training, public education and
              establishment of community cooperation.  It will utilize the resources of
              the Cancer Teaching Projects, the IRMP Tumor Registry and of Core Administra-
              tion's Health Care Data Bank for followup and evaluation.  The expertise of
              the Core staff's Communications and Information Service will be utilized
              in community relations, preparation of publications and news  releases.
              This will be the first time IRMP's cancer activities will be extended to
              the area of early detection, as well as fostering a cooperative venture
              between medicine and dentistry.
              A two-hour intensive refresher course will first be presented to the local
              physicians and dentists on the differential diagnosis and treatment of head,
              neck and oral cancers.  This will be in the form of two 16 mm. color movies
              and supplemented by visiting consultants' lectures using 35 mm. color slides.
              Diagnostic procedures will be illustrated.  The following day a screening
              clinic will be held and these are designed to evaluate 500 persons.  This
              will require eight examination booths, four staffed with IRMP physicians,
              dentists or consultants, and four staffed by local physicians and dentist
              on a rotating basis.  As far as possible all Pap smears and biopsies will
              be performed during the clinic. An IBM key punch card,  designed  as  a
              combination registration and patient information card will provide for
              efficient data handling.
              Informative evaluation will be conducted during the entire term of the project
              in an attempt to make the clinical learning experiences most meaningful to
              the practitioners as well as acceptable to the patients and communities.
              Increased diagnostic attention to oral, head and neck lesions  will  be
              assessed by the use of Core Administration's Health Information Data Bank.

              2nd Year:  $70,426                                  3rd  Year:  $74,533


                                                                        GRB   5/14/70









                                   SUt,il,!A,R'i' OF R)7@VID,7 AND COIICI,USION OF
                                       JUNE 1970 REVIEW COI\IMITTEE


                                 INTERMOUNFAIN REGIONAL MEDICAL PROGRAM
                                             R14 00015 7/70.1

                           FOR COIISIDERATION BY JULY 1970 ADVISORY COUNCIL


             General:  The  Committee  recommended  that  this  single  component  application
                        which requests @217,226 for a three-year program period be
               returned for revision.

             Project f,-27 - Head.,. Neck and Oral Cancer Dotectio
             Lr@ti@ic:  It was recognized by tlip. reviei@..,@rs that the application has
                         many good aspects, the leading one being the involvement of
             dentists, xqliich is not a simple affair. Also,  the  Region  has  an  ongoing
             cancer registry, and the "cooperative  venture"  betvieen  medicine  and  den-
             tistry was considered  unique  and  undoubtedly  based  on  sound  relationships.

             There were, however, a number of reservations about the project.  First
             of 611-, it seems doubtful that local practitioners -would  be  able  to  fol-
             low through on the  results  of  the  feasibility  study.  An  outstanding  dis-
             advantage of a floating clinic is the improbability of follow-up.  The
             Region apparently did  not  give  sufficient  thought  to  evaluation  measures,
             which would result from the essential follow-up.

             The reaching team is available,  but  the  Region  fails  to  include  documenta-
             tion for its organization.  There were no curri.ct).Itim vitae included, no
             indication of the leadership or qualifications of team members.

             The project planners have not  spelled  out  the  relationship  of  this  project
             to the ongoing cancer registry. There  does  riot  appear  to  be  a  centralized
             biopsy review, and no apparent relationship to the broader aspects of
             cancer screening.    There was another more philosophical  concern  whicl-i  was
             related to what appears to be a somewhat fragmented diagnosis,i.e.,
             about the sub-speciall@i.es such as thvroid tumors  that  will  be  uncovered?
                                                    I

             The reviewers a-reed that failure to narie a qualified head and neck surgeon
                             0
             or to identify faculty i,;bo made the  judgment  necessary  for  proposin-  such
                                                                                     LI
             training, the project lacks many of tl-ic.cleni(!ncs necessary for  its  success.
             Recommendati.or-t:  Non-Approval II - return for revision to include the
                                the follo@@ing: (1) Statement of project's relation-
             ship to the broader cancer  screening  program;  (2)8tat(@irent  of  anticipated
             follow-up procedures; and ('@'j indication  of  the  leadership  and  qualifica-
             tions of the reaching team.





                                                                          RMPS/GRB/7/7/70

















            0                                                              0                                                              0





                                    REGIONAL MEDICAL PROGRAMS SERVICE
                          SU14WkRY OF AN OPERATIONAL SUPPLEt4ENT GRANT APPLICATION
                                           (A Privileged Communication)
            KANSAS R,r@(,'I.ONA,L MEDICAL PROGRAM                    RM 00002  7/70.1
            3909 Eaton                                               June 1970 Review Committee
            Kansas City, Kansas  661.03

              ,; 't 11
            PRO('t?,i-',4 (00[tDINATOR.  Robert W. Brown, M.D.
                                 Ist    Year     2nd    Year     3rd Year       4th     Year     TOTAL
            I)I@re(-,t Costs       $111,959.     $123,680        $133,230           $142,881     $511,750
            Irid! e(@t Costs          29,258          34,376       37,454             40,804        141,892

              'AL                  $1-41,217                     $170,684          .$183,685     $653,642
                                                 $158,056
                          Planning in this Region began almost four years ago in July 196
                          'Ihia first operational grant was awarded one year later.  The
            Region was awarded $2,536,975 for a 14--month period,          of which $1,307,406 is
            fe@@,       A  new  Coordinator,  Dr.  Robert  Brown,   was   appointed   in   February   1969.
                      site visit to this Region was held in January 1969.
            'rte,,! ciij,zat-iort of the Region stresses subregi.onalization.  Twenty-one Local
            i@ @-, t'i @@) @@'i .;rc)ups, whose membership overlaps with Comprehensive Health Planning
                         .@,evi                                            search, Planning and
                              el%? proposals before they reach the Re
            Develol)in;--tit- Committee, Scientific Advisory Subcommittee and Regional Advisory
                     The  Kansas  RMP  core  staff   structure   also   provides   for   four   subregional
                            who work with both the planning and operational activities and
            113.!  L@x(-,c@utive  secretaries  to  the  Local  Advisory  Groups.  Subregional  offices   in
            Wic@iita, Great Bend, Topeka and Colby are presently staffed.
            t@l n,,@ of   proposals the Kansas FMP has submitted have dealt with training
                    and          health personnel, as does the one in the present application.
                      reviewers have noted this emphasis and recommended that the Region
                     a better mechanism for defining priorities and developing a coordinated
            apl)i,,()acii Lo training these groups, as well as physicians.

                                                                                                     Requested
                     11--39 -- A...Dciiionstration P                                                 First Year
                             Illness Care.  The Committees on Public Hea t  an                       $111,959
                     Service                  ee County Medical Society - after reviewing
            data c.)ri iiie4ii.cal care  in  adult  care  facilities  --  concluded  that  neither
            now tioi., ir@. the forseeabl.e future will it be po@,-sible for local physicians
            to I)rr)-,@i.de all the inedi.cal care the aged chronically ill population
            reqiiit,@@s, and they requested that Topelra-Shawnee County Health Department
            (I       a  plan  for  public  health  care  nurses  to  assume  a  portion   of   the
                      load.  There are 21 licensed proprietary homes and a 55-bed
                                 infirmary in the county.
            ,nick Tr.)peka-St-iawnee County Health Department, in conjunction with the
            @il.@aw,riee nty Medical Society, have developed a fotir-year demonstration
            project   to:   1)   establish   within   the   Topeka-Shawnee   County   Health





            KANSAS REGIONAL MEDICAL PROGRAM           -2-                 RM 00002  7/70.1


            Department a special, multi-discipline chronic disease team  and.  to
            2) develop a nurse-clin-ician.

            The Comprehensive Health Team will consist of  a  nurse  coordinator,
            physical therapist occupational therapist, dietician, social
            worker and two registered nurses.  These individuals will be
            recruited, selected and directed by the Health  Department  Director.
            The team's function will be to assess patients  in  selected  nursing
            homes, to be followed by assessment conferences in  which  personnel  of
            the home participate; and evolve a total treatment  plan  and  determine
            the need for basic instruction and continuing consultation  to  carry
            out that plan.  The program will emphasize supplementing, reordering
            and improving patient care, not displacing the current efforts of
            physicians or the adult care facility staff.  In later phases of the
            program, the team will concentrate on specific training program
            development, utilizing such existing community resources as the area
            vocational school, hospitals, physicians,  Washburn  University,  and
            an anticipated model long term facility.

            A nurse with a bachelors degree and some experience in  teaching  and
            supervision, who will eventually assume responsibility  for  organizing,
            supervising and referring the "practicum" for other nurses, and a
            recently graduated nurse, who will handle patient care in local
            nursing homes, will be trained as nurse clinicians.  A  curriculum  will
            be developed to prepare the nurses to provide  psychological,  education
            and medical services to the patients. During the  second,  third  and
            fourth years of the project, the proposers hope to offer  the  course
            two or three times a year depending on its final form and direction,
            for a total of 28 to 35 nurses.  Certain members of the Health Department
            staff and the Coordinator of the comprehensive care  team  will  provide
            leadership and direction for the initial training  course.  A  panel  of
            nurses representing several related nursing specialties  will  serve  as
            a consulting committee to review and advise on  the  nursing  components
            of the program. The panel chairman of this group will  serve  on  the
            Advisory Committee of the project, along with the clinical  director  of
            the mental health corporation, two physicians, three laymen, a hospital
            or nursing home administrator., and a welfare department representative.
            The proposers have planned for several forms of evaluation,  such  as
            studying patient records, observing nurse clinician performance, inter-
            viewing patients and analyzing statistical records.

            The first year budget consists principally of personnel  ($75,563),  but
            also includes funds for consultants ($20,000). equipment ($4,946),
            supplies ($I,,300), travel ($7,200 and other ($2,950).  If  the  program
            serves the community as expected, adequate local  funding  through  some
            consideration of fees, contributions and support from public and private
            agencies appears reasonable by the end of the project period.

            Second Year:  $123,680    Third Year:  $133,230      Fourth Year:  $142,881





                                                                          5/11/70





                                                            KANSAS REGIONAL MEDICAL PROGRAM
                                                            RM  00002  7/70.1
                                                            A Privileged Communication


            STAFF OBSERVATIONS


            Summary of Review Actions

                                                                       STATUS   AND
            PROJECT                                                    CURRENT SUPPORTI
            i@l  - Educational Programs (Great Bend)  renewal             $303,655

            #2  - Reactivating Nurses (Great Bend)                         Terminated

            #3  - Circuit Course for Active Nurses                          29,968

            #4  - Cardiovascular Nurse Training                            180,918

            #5  - Cancer Detection                                         Terminated

            #6  - Physical and Occupational Workshops                      Terminated

            l@7 - Cardiovascular Work Evaluation                           Terminated

            #8  - Continuing Education for Cardiac Care                     82,162

            #9  - Metropolitan Kansas City Nurse Retraining                 85,365
                     Program

            i@10 - Health Data Bank                                         34,495

            #11 - Self-Instructional Centers                                17,050

            Y@12 - Training Program for Cancer of Gastr  o-               Withdrawn
                     intestional Tract

            #13 - Project Stroke                                          Deferred

            l@14 - Perceptual Motor Dysfunction Assessment and            Terminated
                     Treatment


            Y@15 - Physical Therapy Workshop                              Terminated

            #16 - Therapeutic Nutrition                                   Terminated

            #17 - Cancer Chemotherapy Seminar                             Terminated

            @t'18 - Core                                                   1  307,406

            #19 - Hypertension Screening Program (earmark)                Phased  out by
                                                                            the Region

             20 - Continuing Education Program for Occupational           Completed
                     Therapists





            KANSAS R-T,!P STAFF OBSERVATIONS                                   RM 00002 7/70.1
            #21 - Cerebrovascular and Neurological Nurse Training           58,059
            #22 - Biomedical Lib rary  Information  Center               Combined with #23

            #23 - Kansas Medical Library System                           222,094

            #24 - Food Service Personnel Using the Dietary                  3,175
                    Consultant Approach

            #25 - Coordinated System for the Continuing Education           58,779
                    of Medical and Paramedical Personnel

            #26 - Cancer Care Continuing Education Program                  12,630

            #27 - Proposal for a Renal Dialysis Organ                    Disapproved
                    Transplant Program

            IF28 - Seminar on Basic  Medical  Librarianship                 6,050

            #29 - Kansas City Council  on  Health  Careers                Approved  but  Unfunded
                     Manpower Recruitment Program
            #30 - Mobile Workshop for Medical Technologists               Returned  for  Revision

            @P31 - Subregional Office in Topeka (Core)                      59,609

            #32 - Institute for Dieticians                                  18,264

            #33 - Nursing in Long Term Illness                            Disapproved

            #34 - Proposal for a Basic Continuing Education               Returned  for  Revision
                    Program in  Community  Health  Nursing

            #35 - Basic Educational  Program  for  Medical                Returned  for  Revision
                    Record Clerks in Hospitals in Kansas

            l@36 - Short Course in Instrumentation for                    Returned  for  Revision
                    Medical Technologists

            Y@37 - Care of Patients with Fluid Electrolyte                  57,296
                    and Renal Problems
            #38 - Basic Educational Program for Medical Record            Approved  but  Unfunded2
                    Clerks Employed in Hospitals in the State
                    of Kansas
                                          TOTAL                          @2,536,975

            I.- all amounts are for 14 month period
            2   funding under negotiation from the $5 million earmarked funds




                                                                                   4/27/70







                                                              ri.vileged Coutmunication
                                                           A P


                            SUM-AARY OF REVIEW AND CONCLUSIONS OF
                                 JUNE 1970 REVIEW COMMITTEE
                              KANSAS REGION@I, MEDICAL PROGRAM
                                      RM 00002  7/70.r

                      FOR CONSIDERATION BY JULY:1970 ADVISORY COUNCIL


              General.:  Review Committee recommended return for revision of this one-,.
                        project ap lication which requested $653,642 for a four-vear
                                  p
              program period to support A Demonstration Project to Improve Community
              Chronic Illness Care.  While the reviewers believed that the venture
              into a new type of profession - the nurse clinician - is a laudable  one,
              they found certain weaknesses in the project design which make it
              unapprovable in its present form.


              Project #39 - A Demonstrati         t to Improve Coimnunity_qhronic
                            Illness Care

                         The Continuing Education and Training Panel described this
                         proposal as "primarily a service--centered project with a
              continuing education component."  They were critical of the l.ack of
              information about the educational design, including curriculum and  rein-
              forteuient of learning, the evaluation, staffing and bud-et.  @lhi-le Com-
              mittee thought that this project had shown evidence of area interest  and
              documented the need, they essentially agreed with the Panel.  The Commit-
              tee also stated that the proposal had not planned for the patients  after
              discharge from the service and had no -%visible tie to the University of
              Kansas School of Nursing. Some concern was expressed about  how  patients
              wbtild,be fed into the system.
              Recommendation:  In returning this project for revision, it should be
                               stressed to the proposers to:
              (1) strengthen the evaluation
              (2) plan for patients after discharge from the service, and
              (3) show ties to the University of Kansas School of Nursing,













                                                                      DPIIT  7/i/70

















    @ 0                                                                    0                                                              4








                                     REGIONAL MEDICAL PROGRAMS SERVICT
                        SUMMARY OF AN OPERATIONAL SUPPLEMENT GRLNT APPLICATION
                                       (A Privileged Communication)


                LOUISIANA                                               RM   00033   7/70.1
                Regional- Medical Program                               June  1970 Review Committee
                271-4 Canal Street
                New Orleans, Louisiana  7011-2


                PROGRAM COORDINATOR:  Joseph A. Sabatier, Jr., M. D.

                Requested              lst   Year      2nd   Year      3rd   Year      Total

                Direct Costs           $519,992          $288,964        $288,886      $1,097,842
                Indirect Costs             27,666          29,050          30,501         87,217


                TOTAL                  $547,658          $318,014        $319,387      $1,185,059

                HISTORY:  The  initial  planning  grant  was  awarded,   after   being   returned
                            for  revision,  in  January  1967.  The  second  year's   award   was
                made in March  1968.  The Region submitted its first operational applica-
                tion in August  1968, but the Review Committee and Council did not
                believe the materials reflected readiness for an operational program.
                Council  recommended  that  the  application,  which  included  a   project   for
                Delineation  of  Medical  Service  Regions  in  Louisiana  and   a   Health
                Careers  Recruitment  Program,  be  approved   as   planning   activities.   Core
                funds  were  also  approved  as  requested  to  strengthen  the  central   staff.
                The Region's second operational submission was approved by the August
                1969 Council and includes funds for the following projects:
                      #1 - A Training Program for Tumor Registry Secretaries               $116,956
                      #2  - Proposal  for  Teaching  Conferences   for   Diabetic            25,000
                            Patients
                      #3  - Proposal to Establish an  Office of Research and              106,954
                            Development in Educational Renewal (ORDER)
                      #4  - Audiovisual Lecture Demonstrations in Radiology                  24,791
                            and Radiologic Techniques
                                                                                           $273,701

                Proj.ect #5 - Development of a Regional Medical Center Coro              Care
                                TraipiLn   nit, a two-year $535,747 request for equipment
                was withdrawn by the Rggion after the November 1969 Review Committee
                meeting.




            LOUISIANA                                            RM 00033 7/70.1
            Regional Medical Program

            The amount of $327,303 for core and $72,883 for the planning studies
            bring the Region's total funding level to $673,887 (d.c.o.).
            The Lou:Lsiana Regional Medical Program has conceived its rol,e as a
            catalyst in effecting peripheral involvement and cooperative
            arrangements. A formal review process has been organized with staff
            assistance, Ad Hoc categorical review, and Regional Advisory Group
            evaluation and approval as the key elements.  Planning committees
            have been developed in Heart Disease, Cancer, Stroke, Health Manpower
            and Continuing Education, Epidemiology and Statistics, Public Relations
            and Information, and Subregional Relations  and Project Consultation.
            There are 17 persons on the core staff, including 14 professionals.
            Part-time advisors from Louisiana State University and Tulane University
            furnish liaison with their respective institutions.
            Planning studies the staff are currently working on include:  1)
            operations research in preparation for the establishment of a statewide
            cancer registry; 2) reduction of health care costs through voluntary
            cooperation among medical laboratories; and 3) consultation assessment
            of the administration and software activities of the statewide closed
            circuit medical TV network.
            Since the last site visit in June  1969, the Region has made several
            organizational changes.  The grantee institution has been changed from
            the Louisiana State Department of Hospitals to the Louisiana Regional
            Medical Program, Inc., a non-profit corporation.  The Regional Advisory
            Group has also been reorganized to give more representation to allied
            h4:!alt'n and -nii:ority groups.
            PRESENT APPLICATION:  The Louisiana Regional Medical Program has
                                  included a short introduction to the application,
            which summarizes the projects and also describes four projects which
            were re.-iectp-d by the Regional Advisory Group.  At the end of each
            project, fairly extensive comments of the Ad Hoc Review Committees
            which reviewed the projects are given.
            Project #8 - Cardi6Dulmonary Resuscitation Program. The goal          sted
                         of this project is to increase the number of        First YtAt
            trained personnel in CPR techniques in order to significantly    T172,-755
            reduce the mortality from cardiopulmonary failure in Louisiana.
            The Louisiana Heart Association as the sponsoring organization
            seeks funds to determine the extent of CPR training and the current








             ],OUISIANA                           -3-                 RM  00033   7/70.1
             Regional @t(@dical- Program


             l(@@v@-I of competence of individuals involved  in  CPR  programs  in  the
             state and then to  establish  a  statewide  program  to  train  and  re-train
             at periodic intervals such groups as practicing and resident
             physicians,  registered  nurses,  licensed  practical   nurses,   dentists,
             safety and law enforcement personnel, firemen, general hospital
             personnel and families of cardiac patients.

             To accomplish  these  objectives,  a  full-time  employee  of  the  Louisiana
             Heart Association, preferably a physician, will be appointed as
             director for the program to 1) organize the training programs, 2)
             coordinate  the  faculty  and  instructors,  3)  maintain  and  distribute
             supplies  and  equipment,  4)  assist  with  establishing  record  keeping
             procedures and  collection  of  data,  5)  provide  liaison  with  hospitals
             and other related groups,  and  6)  coordinate  and  assist  in  the  overall
             evaluation.

             lie will. be assisted by physicians who will serve as senior faculty members.
             Their  responsibilities  will  include  the  regular  organization  of  CPR
             training programs  in  an  area,  consulting  with  hospitals,  planning  and
             implementing CPR procedures and evaluating program instructors.

             The state will be divi.ded into four districts with a full-time district
             director to implement and coordinate the local programs.  This indivi-
             dual. would be paid $12,000 per  year  and  required  to  have  knowledge  of
             and training  in  community  organization  and  some  knowledge  of  cardio-
             pulmonary resuscitation.

             Adequate secretarial help  will  be  provided  at  the  central  office  and
             district office  level  to  maintain  recor4s  and  dispense  material  and
             equipment. The Heart Association will also make available time, equip-
             ment and "all of its organizational knowledge."

             Prior to initiation of the training programs, the director will attempt
             to determine the present extent of CPR training in Louisiana.  To
             accomplish  this,  physicians,  nurses,  dentists,  and  hospital   ambulance
             drivers will be given  a  written  quiz  and  a  practical  evaluation  of
             performance of  CPR  procedures.  On  the  basis  of  experience  with  con-
             ducting CPR  programs  since  1960,  the  Heart  tssociation  estimates  that
             200 instructors will be needed in a minimum of eight hours of instruc-
             tion per year to train and re-train the necessary personnel. Re-training
             sessions will be held every six months.

             Evaluation will consist of an assessment of how many people were trained
             and what are the results of thetraining.  The number of new CPR programs
             established  within  hospitals  and  the  mortality  figures  following  CPR
             attempts will also be appraised.




           ILOUISIANA                        -4-                  Rm 00033 7/70.1
           Regional Medical Program
           The bulk of the request is for personnel. The Ileart Association  will
           assume responsibility for insuring that hospitals have enough  trained
           individuals After RMP support has been terminated.
           Second Year:  $152,875                   Third Year:  $158,912
           Project #9 - Metropolitan New Orleans Or     ank. The proposal         sted
                        states that at the present time, there is no         First Year
           coordinated, organized, centrally directed effort to promote       $128,025
           the development of an organ bank for the methodical procurement,
           preservation and supply of vital organs for purposes of renal
           transplantation in New Orleans.  In New Orleans there are 41
           dialysis facilities in six separate hospitals.  These facilities
           can maintain approximately 123 patients.  No facilities exist out-
           side New,Orleans at present.  Thus, the proposers feel that a
           feasibility study is indicated to:
                 1)  facilitate maximum utilization of cadaver organs on a
                     local basis,
                 2)  determine practical guidelines for kidney preservation,
                 3)  reach more definite answers regarding the efficiency of
                     tissue typing in cadaver organ transplantation,
                 4)  identify methods and resources for generation of  continuing
                     financial support,
                 5@  detionstrate need for additional banks,
                 6)  determine appropriate location of additional banks,
                 7)  determine feasibility of storing organs other than  kidneys,
                 8)  utilize relationships which accrue the widest and optimal
                     application of transplantation capabilities to patient
                     benefit, and
                 9)  determine useful sources of organ supply.
            'Eiie central headquarters of the organ bank will be located in Charity
            Hospital of New Orleans, where there will be a telephone manned on  a
            24-liour basis to enable physicians in any participating hospitals
            let the bank know when a donor becomes available.  Bank physicians,









               I,OTJ I S IANA                     -5-                RM 00033 7/70.@l
                        Mc@dic@il Program


               assigned on a rotational basis, will- arrange for perfusion and
               necessary transportation of the kidneys.

               The director of each transplantation program, the tissue typing
               technician on call, the physician responsible for  procurement  of
               organs, the perfusion technician on call and the director  of  the
               tissue typing laboratory will be provided with a two-way radio
               transmitter to keep them in touch  with  central  headquarters.  From
               computer comparison o  bloo  type data on file, the appropriate
               recipient will be selected and the perfuming organ will be
               delivered to the recipient's hospital and transplanted.

               The organ bank will be directed by a Council which will develop
               priorities, aims and community support and advise  proper  approaches
               to obtain continued funding.  The Council will be broadly representa-
               tive of the organizations and institutions involved in organ
               transplantation.

               Assisting the Council will be a Subcommittee for Delivery of Services
               which will be responsibile for the actual mechanics  of  obtaining
               organs, selecting the appropriate recipient and providing it to
               that individual.  It will be composed of two representatives of each
               institution performing kideny transplantation.  Data analysis and
               evaluation will be the on-going function of this committee.

               The first year request consists mainly of personnel, equipment and
               se rvices.


               Second Year: $79,692                       Third Year:  $81,792

               Project #10 -A Pilot Project for the Establishment of a Method      Requested
                            of Evaluating the Health Care Delivery Patterns        First Year
                            of Medically Indigent Persons with Heart Disease,      $49,797
                            Stroke, Cancer and Related Diseases.  Because those
               who need health services the most often are unable to pay  for  them,
               the Region believes that steps must be taken to identify and evaluate
               health care patterns, analyze suitable alternative systems of health
               care delivery,and plan to implement programs designed to meet health
               needs of the medically indigent.  To this end, the Louisiana Capital
               Area Health Planning Council, a 314 b agency, will initiate  a  pilot
               study to determine health care pattern characteristics of low income
               residents in Baton Rouge, Hammond an  New Roads.  The project  irector
               will be supervised by the Executive Director of the CHP b  agency.






             LOUISIANA                             -6-               RM 00033 7/70.1
             Regional Medical Program


             The specific objectives    include the following:

                   1)  investigate  efficient  and  reliable  methods  of  securing
                       data on medically indigent in the three areas:@@

                   2)  develop a prototype of research met   hodology usable by
                       similar area councils,

                   3)  develop a uniform system of mapping flow of indigent
                       patients,
                   4)  analyze ecological factors which in@luence t    he  'pattern
                       of health care,

                   5)  determine the need  for  special  planning  to  meet  signi-
                       ficant incidences of particular diseases, and
                   6)  determine the adequacy of the existing system of health
                       care of the indigent.
             As the particular  methods  and  techniques  "have  not  yet  been  completely
             specified," a large part of  the  project  will  be  to  work  out  foasiblo'
             methods.  Essentially,  however,  the  survey  will  attempt  to  1)  identify
             the ty@pe/number of medically indigent  in  the  area  by  a  formula  method,
             2) detect unmet health  needs  by  examining  hospital  records  for  unpaid,,
             high level  bills,  determining  the  extent  of  indigent  patients  treated
             by  private  practitioners  and  contracting  schools,  welfare   departments
             and public health nbrses; 3) collect data on payments made to
             practitionere, hospitals and cl@inic@, and 4) compare family incomes
             with treated or untreated conditions.
             Interviewers will  be  hired  from  students  at  Louisiana  State  Universit"
                                                                                         y
             and Southern University.  The,students will interview household members'
             in one  poverty and one lower middle class neighborhoods to obtain
             information on economic characteristics of the household hospitalization
             experience and on doctors' and dentists' visits.
             The proposer  hbpes  to  form  an  Ad  Hoc  Co@ttee  on  Comprehensive  Health
             Services for low income citizens which might help evolve a plan for
             a comprehensive  health  service  deliverv  system  for  low  income  citizens
             having  in  urban  target  areas.  Such  a  system  would  include  outpatient
             services in  a  neighborhood  health  center,  niultiphasic  screening
             services and  use  of  low  income  citizens  in  sub-professional  positions.







                LOUISIANA                            -7-                 RM 00033 7/70.1
                Regional Medical Program


                The proposers believe that these objectives can be achieved within
                one   year.


                Second Year:  None


                Project #11 - Lymphomatous Tumors in Louisiana.  Because           Requested
                               Hodgkin's Disease carries good prognosis            First Year
                when diagnosed and treated early, especially in young adults,  $56,621
                newly occuring cases within Louisiana need to be reported
                to appropriate medical resources so that the patient may be
                effectively treated; clues to  etiologic  events  may  be  studied
                and differences between mortality  in  the  South  versus  the  East
                mav be studied.


                Within three years, the proposers on the staff of the Tulane
                University School of Public  Health  and  Tropical  Medicine  hope
                to attain the following:

                       1) Establish a  statewide  surveillance  system  for  identi-
                          fication and histologic  classification  of  all  newly-
                          diagnosed cases of Hodgkin  s  Disease  occuring  within
                          a two-year period.

                      2)  Through LRNP coordinate the availability of the State's
                          medical facilities to assure the latest diagnostic
                          evaluation, treatment,  patient  care,  extended  survival
                          and, perhaps, cure for each case.

                      3)  To interview each new  occurrence  to  determine  possible
                          etiologic events, especially those identified as
                          occuring around puberty and which  may  be  amenable  to
                          preventable measures.

                      4)  Determine the incidence of Hodgkin's Disease in New
                          Orleans from 1951-1960 by a survey of existing records.

                      5)  Measure the survival status of cases ascertained through
                          retrospective incidence study.

                Personnel costs will comprise the main charge to this project, as
                funds are requested to support part of the project director's salary
                and a full-tim  nurse,  research  assistant,  secretary  and  clerk-
                typist.

                Second Year:  $46,994                  Third Year:  $48,182






                                                                 RM 00033 7/70.1
            LOUISIANA                         8-
            Regional Medical Program

                                                           the Use of              sted
            Project #12            of Elo-ctrocardiograT                     First Year
              usual sma                        full-time                     T10-5 5 3 6
            and since such hospitals have not been able  to maintain
                                          echnician on  a reasonably
            a specially trained nurse or t   e unit, the Sara Mayo
            permanent basis in a coronary car
            Hospital of New Orleans proposes a study of the use of
            telemetry of electrocardiograms from an intensive coronary
            unit in the hospital to any of a panel of cardiologists
            located elsewhere in overcoming those difficulties.
            The unit would include the usual devices for electronic
                                               a multitrace oscilloscope
            monitoring of patients, including
            at the central nurses desk but with the addition of telephone
            transmission equipment to transmit EKG's to the cardiologists'
            own remote read-out equipment.  When the attending nurse notes
            a suspicious rhythm on the scope, she would relay the signal
            to the cardiologist, who would give back diagnostic informa-
            tion for treating any dangerous arrhythmia detected.
            An additional method of transmission, using an FM radio paging
                                                                       I
            service which could broadcast the QRS translated into a 'beep
            would allow the cardiologist to use a portable radio receiver
            ather than          ier read-out equipment.
            r          the bulk
            The project will focus on coronary care treatment in the early
            detection and treatment stages.  While, the coronary   .care unit has
            four beds, several private rooms, the surgical recovery room and
            obstet,,-ic8 unit .,,o,lild be connected as well to the central moni-
            toring station and the treatment compared to that of the central
            unit. In addition,  this  proposal  will  include  telemetry  trans-
            mission of EKG's from St.  Tammany  Parish  Hospital  in  Covington,
            Louisiana to the panel of cardiologists.
            Evaluation @will consist of a comparison of the mortality rate
            in the hospital with a goal of 17%, and an assessment of the success
            of telemetry as a substitute for having an experienced
            electrocardiographer in the unit at all times.
            The funds requested are entirely for equipment.  The hospital
            states it is completing a new  building,  it  serves  a  low  income
            segment of.the New Orleans  population,  it  has  no  endowment  and
            thus does not have the funds to purchase the bulk of the equipment
            required for  the  monitoring,  telephone  and  radio  transmission.

            Second Year:  None






             ],Ot!ISIANA                      -9-               RM 00033 7/70.1
             Regional Medical Program


             l@'roject #13 - A Proposal to Establish a Continuina Education  Requested
                           Program for the Physicians of the Lincoln         First Year
                           General. Hospital, Ruston, Louisiana.  The          $7,258
             physicians of Ruston, Louisiana are currently developing a
             plan to supply health care services to the medically  indigent,
             which comprise one-third of the parish  population.  operation
             of the plan is expected to begin in September 1970,  with  a
             continuing education program antedating the overall plan  by
             one year. Because they believe a continuing  medical  education
             program is a necessary component of the overall plan for
             delivery of health services, the proposers seek to deve op a
             structured program to upgrade skills in their respective
             specialties.

             Physicians from Lincoln General will spend two weeks in  appro-
             priate specialty departments at Baylor College of Medicine  in
             Houston following individually designed programs in their
             specialty.  PrograrLs have been arranged for pediatrics (endocrine
             and cardiac), pathology (surgical and cytological),  surgery
             (vascular cardiology and cardiac pacemakers), and  pediatric
             neurology. Additionally, individualized  physician  programs
              'll be arranged for other departments during the first  twelve
             wi
             months. The second year, faculty from Baylor  Medical  College
             will spend time at Ruston as consultants and observers of health
             problems in a rural area remote from a medical  center.  The
             proposal states that Baylor College of Medicine is the  natural
             referral source for difficult cases for physicians in the  area.
             Results of increased training will be applied to other  programs
             in which the physicians participate, such as those sponsored  by
             the parish health department, Family Planning, Inc.,  Department
             of Public Welfare, Ruston Area Mental Health Clinic, etc.,
             as a spin-off effect is generated.

             Sophisticated evaluation of behavioral changes will not be
             attempted but documentary records will be kept and an  overall
             evaluation attempted.

             Funds are requested in the first year for travel an in  t  e
             second year for travel and consultation fees.

             Second Year:  $9,403                  Third Year:  None






                                                      DRNP/GRB
                                                      5/21/70







                                                                A Privileged Communication



                               SUMMARY OF REVIEW AND CONCLUSION OF
                                    JUNE 1970 REVIEW COT*IITTEE


                               LOUISIANA REGIONAL MEDICAL PROGRAM
                                          RM. 00033  7/70.1

                           FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


              General: The  Louisiana  RMP  submitted  a  supplemental  application  for
                         six projects requesting $1.,185,059  for  a  three-year  program
              period. The Committee  concluded  that  the  application  be  supported  as
              follows: $147,532 the first year  to  support  Projects  #9  and  10,  and
              $77,242 the second and $79,342 the  third  year  to  support  Project  #9.
              Projects #11 and 1.3 were approved without funds; Projects #8 and 12 were
              returned for revision.

              The reviewers noted that the projects in this application did not appear
              to have kept pace with the  Region's  stated  priority  of  improved  medical
              care for the disadvantaged within the context of cooperative arrangements
              between individuals and organizations concerned with health care delivery.
              Of the six projects in the application,  only  tAo  dealt  directly  and  one
              tangentially with this priority.

              Committee was pleased with the project summary  and  internal..  review  sys-
              tem the Region has developed.  The Ad Iloc Committee Reports were partic-
              ularly helpful to the reviewers.


              Project #8 - Cardiopulmonary Resuscitation
              Critique:  The Committee did not approve this project because of the ntim-
                          ber of unanswered questions that arose.  For instance, they
              were unable,to ascertain how many PeODI.e would  be  trained  or  the  train-
              ing time involved. Also,  the  application  did  not  give  much  information
              about previous experience with this activity in the state.  Certain budget
              items, such as personnel,  instructional  materials  and  the  $11,000  for
              telephone, were not adequately justified.

              Recommendation:  Non-Approval II (revision required).


              Project #9 - Metr,-IPOI!tan OrRaii Bank

                          The Co.,,-tmi.t@ee recopi-inended approval of this project.  The budget
                          is well justified.  An  evaluation  procedure  is  planned  which
              would document the nuTLber of ki.eineys received and used,  and  study  the
              function of grafts aiid'the relationship o--r biolo,-ic couipatability  to







              Louisiana RNP                      2                      RM  00033  7/70.1


              function. A broadly representative council would  have  as  one  of  its-
              functions the responsibility fo@'-',in@i.ng other means of support  after
              EMP funds are no longer  available.  Although  physician  education  was
              not a part of the project, some reviewers thought  this  type  of  project
              would lead into an educational process.

              The Committee agreed that the two-way radio network,  the  truck  and  the
              Belzer perfusion equipment were unnecessary,  especially  since  most  of
              the procedures will be done in New OrleAns in the beginning.

              Recommendation: Approval I with reduction  in  the  budget  as  outlined
                               above.

                           01                       02                        03
                       $97,735                  $77,242                   $79,342


              Project #10 - A Pilot Project for the Establishment of a   Method of Evalu-
                            atin& the Health Care Delivery Patterns of   Mbdicall-y Indi-
                            gent Persons with Heart Disease, Stroke, Cancer and Related
                            Diseases

               -iti able: The Continuing Education and Train-'Lng-Branch staff found that
                         the need for the study based on  the  assumption  that  adequate
              data in existing health care delivery patterns  of  the  target  population
              must be compiled before a comprehensive  health  service  delivery  system
              tan be designed is valid and well substa ntiated.  The  time  frame  and
              staffing appeared reasonable, and good use  of  regional  resources  has
              been planned.  The extensive evaluation plans seem adequate.
              The Committee agreed with  these  statements.  Some  reviewers  expressed
              the wish to have had some information on the pilot  study  in  Eden  Park
              and some documentation of cooperative arrangements.  Concern was expressed
              as to whether the patients and local physicians would be amenable to the
              collection of data on unpaid bills.
                    I
              Recommendation:  Approval in the amount and for the time requeste
                               ol - $49,797


              Project #11 - Lymphomatovs Tumors in Louisiana

                         This project directed at a  comparatively  rare  disease  seems
                         feasible and would be  productive.  It  is,  however,  primarily
              of a research nature and centered in  a  medical  school.  Whild  Committee
              believes it is within RMP's purview, they were not  persuaded  that  it  is
              within the Region's stated objective of increasing  health  care  for  the
              d 3'-sadvantaged. The project could  have  considerable  educational  value
              if tied in to a radiological program.







              Louisiana alP                      3 -                 RM  00033   7/70.1


              Recommendation:  Approval II    (No additional funds recommended)


              Project #12 - Intensive Coronary Care Through the U  se of  Telemetry  of
                            Electrocardiograms

              Critique:  This project raised several questions:
              (1) Why is an elaborately equipped coronary care unit  needed  to  test  the
                  transmission of electrocardiograms?

              (2) Will physicians actually be able to detect heart  rhythms  on  the  page
                  beeper device?
              (3) If the personnel in the unit are  sufficiently  intelligent  and  skill
                  to carry out the treatment-indicated by the ECG information obtained,
                  shouldn't they also be capable of assimilating the   knowledge required
                  to identify ECG abnormalities?
              In addition, the Ad Hoc Cardiovascular Study Panel  stated  that  (1)  moni-
               oring by a remote cardiologist would not achieve  the  objective  of  re-
              ducing mortality in the absence of on-the-scene  skilled  medical  or  para-
              tntedical- personnel; (2) documentation of specific personnel resources  is
              lacking; (3) the budget is unreasonable, especially in the equipment
              category; and (4) evaluation is inadequately planned.

              The Com6littee felt the project was an interesting effort  'of a  community
              hospital to get at the problem of  transmitting  and  reading  ECG'S.  How-
              ever, the questions that the project raised and  the  Panel  comments  make
              it unapprovable in its present form. If  the  Region  should  revise  the
              project, the- reviewers advise that the proposers place  particular  ieipor-
              tance on the capability of the individuals at the  hospital  end  of  the
              transmission.

              Recommendation:  Non.-Approval II (revision required).
              (One vote opposed to recommendation)
              Project #13 - A Proposal to Establish a Continuing  Education  P_roRram  for
                             the Physicians of the Lincoln General  Hospital-,  Ruston,
                            Louisiana

              Critique: The reviewers had  difficulty  resolving  their  differences  of
                         opinion into a recommendation on  this  project.  On  the  one
              hand, the Conmiittee saw the value of such an  educational  program  esp6-
              cially in the context of a larger comprehensive health  care  plan  for  the
              community. The Continuing Education  and  Training  Panel  believed  that
              the proposed exchange experience for medical  specialists  in  rural  areas
              would be innovative and that the time frame  and  budget  are  reasonable,
              On the other hand, the proposal wAs unspecific about areas of instruction
              and method of evaluation. The proposers bad  also  neglected  to  include  a
              copy of the payi-sh's Comprehensive Health Care  Program,  which  includes







              Louisiana                          4                 RM 00033  7/70.1


              care for the disadvantaged.

              Committee realized that this project is under  capable  direction  and  has
              confidence that it would probably  accomplish  its  aims.  They  recommend,
              however, that the project directors util-ize the resources  of  the  LRMP's
              Office of Research and Development in Educational Renewal (Or\DER).

              Recommendation:  Approval II - (No additional funds recommended)       with
                               the following conditions:

              (1) Baylor College of Medicine provide a  description  of  the  courses;
              (2) The project directors submit a description of the parishwide plan
                  for comprehensive health care; and

              (3) The project directors discuss and develop with the Office of Research
                  and Development in Educational Renewal a better method of evaluation.


              Conclusion: A total of $304,116 for  three  years  was  recommended  for
                           Projects #9 and 10.


                                                          01             02              03
              Project #8 - Cardiopulmonary
              Resuscitation Program                            Returned  for  Revision
              Project #9   Metro. N.O.               $97,735         $77,242          $79,342
              Organ Bank
              Project #10   Study of Health           49,797             -0-              -0-
              Care Delivery Patterns of
              Medically Indigent

              Project #.Il - Lymphomatous Tumors              Approval  Without  Funds
              in Louisiana

              Project #12 - Telemetry of                      Returned for Revision
              ECG's

              Project #13 - A Continuing                      Approval- Without  Funds
              Educati-or,. Program for
              Physicians of Rust-on, La.

              TOTAL                                    $147,532       $77,242        $79,342





                                                                         DRMP  7/9/70

















            a                                                              0                                                              0









                                 REGIONAL MEDICAL PROGRA14S SERVICE
                      SUMMARY OF A SUPPLEMENTAL OPERATIONAL GRANT APPLICATION
                                   (A Privileged Communication)


               MARYLAND REGIONAL  MEDICAL  PROGRAM                 RM 00044 7/70.1
               550 North Broadwa-v                                 June 1970 Review Coimnittee
               Baltimore, Maryland 21205


               -PROGRAM COORDINATOR:  William J. Peeples, M. D.
                  ested          lst  Year       2nd  Year       3rd   Year      Total
               Direct Costs      $172,045        $173,076          $129,059     $474,180
               Indirect Costs       32,058          35,190           23,243       90,491

               TOTAL             $204,103        $208,266          $152,302     $564,671
               HISTORY:  The Maryland Regional Medical Program began its planning
                         during January  1967.  Following a site visit in December
               1968, and a meeting of a special Reference Committee of Council, an
               award of $1,932,893 (d.c.o.) was made (effective March 1, 1SI69) to
               the Region to support Core  activities  ($724,360)  and  operational
               projects ($1,208,533) - (d.c.o.) for the  first  year.  In  February
               1970, staff reviewed and was disappointed with the Region's progress
               as outlined in the 02 year application.  There appeared to be only
               minimal coordination between the  various  institutional  units  and
               Core Staff, and even less coordination  between  Core  staff  and  the
               individual projects.  Although the second-year approval application
               was in the amount of $2,120,538 (d.c.o.) (see History Supplement for
               breakout of this total), they further recommended that a site visit
               be conducted to "explore the  interrelationships  of  the  Core  staff
               with projects as well as the degree of coordination among the various
               Core components, i.e., Core units."
               Also, March  1970 Council recommended that a November  1969 supple-
               mental operational application be  deferred  for  a  site  visit.  The
               reviewers shared Staff's concern about the  size  of  the  Core  staff
               supported in the Maryland Region and the obvious lack of intramural-
               extramural contribution by this cadre of experts to the regionalization
               process as it was reflected in the supplemental operational application.
               The site visit was conducted on May 11 and 12, 1970.  The report of
               the site visitors will be available to the reviewers during the June/
               July 1970 review cycle.







                     MAR*LAND                                          -2-                              RM 00044 7/70.1
                     @.-gional Medical Program


                     PUSENT APPLICATION:   This application requests three-year support
                                                     for   two   projects    in    the    field    of    cancer    and
                     on        ject in continuing education for dentists.   Direct costs only
                      ,!e@   pro
                     at@-@noted in the following project descriptions.
                     Project #28 - Regional Oncology Affiliation.   Johns Hopkins                                  Requested
                                         University,       Baltimore,       Maryland.       This        proposal   First Year
                     l,s@b-ased on a     Unsupported      feasibility      study      initiated      at       the    $116,151
                     ,Eas.ton    Memorial    Hospital    in     Easton,     Maryland,     and     the     Church
                     IH,oo*,and Hospital in Baltimore.   It is for the establishment
                     @o@f     af filiation between the Johns Hopkins Oncology Center
                     -and    Qther    hospitals    and    an    increasing     number     of     community
                     ,Musicians     in     order,to     provide     comprehensive     care      to      patients
                     ,w,ii4.@.cancer    and    to    provide    a    continuing    education     program     for
                            cians.       The    applicant    states    that    1700     cancer     cases     are
                     'r@.tered     each     year     at     Johns     Hopkins     and     Baltimore      City-Hospital

                     'This  .project proposes to provide multidisciplinary care of patients
                     'by -@'roviding:      1)     24-hour     telephone      consultation      to      physicians
                     -.so.-that patients'  problems and clinical questions can be handled
                     @pro-  tly as they arise;  2)  rapid access to comprehensive evaluation
                            TP
                     of@    ,ambulatory    patients    by    a    specific    panel    of    consultants;    and     3)
                            l@7 ,
                     by providing prompt admission for patients requiring major diagnostic
                     ,.anii.ttreatment procedures.
                     :'The-nina'or emphasis     of     the     educational     activities     will     be     directed
                               clinical application and the immediate improvement in
                     .patient    care    and    will     be-accomplished     through     the     provision     of
                     'Cam '@ity    hospital conferences,  seminars,  and an annual two-to-
                     ,'thr@6, day  course     in     oncology.     A     detailed     automated     record      system
                     ,,vYill@be    used    to    support    all    phases    of     the     program.     Approximately
                     $93,.""OOO   df the  first year total request of $116,151 is for
                     .personnel.
                     l-,@6ec,:ond Year:   $122,426                           Third Year:   $129,059
                     @ro'ect    #29    -    A    Cancer    Detection    Program    in    Children.     The        $ 48,895
                            i
                                         orimary objective of this proposal is the
                     ,earl    detection     and     diagnosis     of     malignancies     in      children
                            'Y
                     dur@tig@the first five years of life.
                     The.,Proj-ect     proposes     to     train     and     u:ilize      non-physician      personnel
                     i.to   @"pnduct     the     screening     program.     Overall      program      supervision






                            , 1,







              MARYLAND                           -3-                RM 00044 7/70.1
              Regional Medical Program


              will be the responsibility of a special advisory committee  com-
              posed of members from the Department of Pediatrics and  the
              Baltimore City Department of Health.  This committee will meet
              periodically to review progress and make general policy decisions.
              Initially, the screening procedures and techniques will  be
              developed in the Comprehensive Health Care Clinic in the Depart-
              ment of Pediatrics at the Johns Hopkins Hospital, and it is
              expected that approximately 25,000 children from East  Baltimore
              will be registered in the clinic by July 1970.  The program will
              later be expanded to include Well Baby Clinics throughout
              Baltimore.

              Some of the screening techniques to be employed are:  1)funduscopy;
              2) abdominal examination for the detection of visceral enlargement
              relating to Wilms' tumor, neuroblastoma and some of the lymphomas;
              3) physical examination; and 4) urinary examination.

              Second Year:  $50,650
              Project #30 - Continuing Education Program - University  of    Requested
                            Maryland School of Dentistry.  The University    First Year
              of Maryland School of Dentistry requests $6,999 for one-year    $6,999
              interim funds to help support the school's continuing educa-
              tion program in its present form while they develop a new and
              expanded continuing education program within the School  of
              Dentistry. The new program will be expanded from  26  continuing
              education courses to 31 courses and will cover most  disciplines
              of dentistry.  This proposal gives no indication of how this
              program will be developed.  Plans are being developed for
              submission of a request for a project grant to support  the
              expanded program.







            MAR@ND RTCIONAL MEDIC,&L    PROGRAM       -4-               Rm 00044  7/70.1

                                              HISTORY SUPPLEMENT

            LI@ti@G OF CURRENT STATUS   OF CORE   OPERATIONAL PROJECTS IN MARYLAND RMP

               A - FUNDED PROJECTS
            Pi6jett                                                   Amount Supportel (D.C.)
            14uiab,er Title                                           Through  2/28/71
                                                                    Basic        Carryover


            00        Core
                        Central Unit                                 $207,504
                        Johns Hopkins University                      98,271
                        University of Maryland                        123,751
                        State Health Dept.                            34,011
                        Epidemiology & Statistical Unit               239,092
                             ical Cancer Program and Registry
                        Clin
                          Feasibility Study (Peninsula General)         3,220
                        Continuing Education Feasibility Study
                          (York Hospital)                             17,946         --
                        Cancer Feasibility Study (Easton
                          Hospital & Joh@ Hopkins)                      4,728        7,272


                                          CORE TOTAL                 $728,523       $7,272

              1       Continuing Educational Program for
                      Peninsula General Hospital                      17,550         --

              2       Development and  Evaluation  of  a  Comprehensive
                      Technical Screening Program for School-age
                      Children of Low-income Families -
                      University of Maryland                          76,816

              3       Early Detection of Cardiac and Malignant
                      Disease in Pre-school Children -
                      Mercy Hospital                                  24,173

              4       A Program for Mass Detection of Heart
                      Disease in School Children - Baltimore
                      City Hospital                                   22,543
              6       Early Detection of Heart Disease in the
                      Newborn - Johns Hopkins                         20,000

              7       Coronary Care Programs
                        A) Univ. of Maryland                          79,700
                        B) Baltimore City Hospital                    21,846





             MARYLAND REGIONAL MEDICAL PROGRAM           -5-            RM 00044 7/70.1
             HISTORY SUPPLEMENT (Continued)
             Project                                                  Amount Supported (D.C.)
             Number   Title                                           Throueh 2/28/71
                                                                      Basic       Carryover
              8       Closed Chest Cardiopulmonary Resuscitation
                      Maryland Heart Association                      38,000
              9       A) Acute Stroke Unit - Hopkins                  103,638        --
                      B) Chronic Stroke Unit - Baltimore City         121,031         58,790
                           Hospital

            10        Acute, Intermediate and Long-term
                      Stroke Care - York Hospital                     145,596        --
            11        A) Proposal on Stroke - University of
                           Maryland                                   138,819
                      B) Proposal on Stroke - Nursing
                           Education - Univ. of Maryland              42,555
                      C) Proposal on Stroke - Rehab. Nursing -
                           Montebello Hospital                        61,714
            12        Proposed Coordinated Discharge Planning
                      Program for Wicomico & Somerset Counties -
                      T@licomico County Health Department             15,083        --
            13        Regional Medical Program for Outpatient
                      Strokes - Deer's Head Hosp. - Salisbury           --           18,594
            14        Demonstration and Training Program in
                      Rehabilitation of Stroke Patients -
                      Sinai Hospital                                163,653         --
            16        An Ambulatory Program for Comprehensive
                      Pulmonary Services - Maryland General Hosp.  90,000
           19         A) Tissue Typing - Baltimore City
                        Johns Hopkins                                                78J.977
                      B) Tissue Typing - Univ. of Maryland            21,642         24,023
                      (Note-  The Division is currently in the
                      process of awarding an additional
                      $20,358 for the first year of this project.)


                                            TOTALS              $1,932,882         $187,656


                              GRAND TOTAL - BASIC AND CARRYOVER          $2,120)538


                                                                                    DRMP
                                                                                    .5/8/70





                                                             :A  Privileged   Communication



                              SUMMARY OF REVIEW AND CONCLUSION OF
                                   JUNE 1970 REVIEW COMMITTEE


                               MARYLAND REGIONAL MEDICAL PROGRAM
                                         RM 00044  7/70.1

                         FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


              General:  The Review Committee recommended that this Supplemental     Opera-
                        ti6nal Application (containing three  individual  projects  and
              requesting $474,180 d.c.o. for a three-year program period) not be
              approved.
              Committee believed that action on Project #28 should be "non-approval
              Prevision r6quired," and that action on Projects #29 and #30 should be
              ionon-approval - no RMPS funding recommended."
              During the F6bruarY/Match 1910 review cycle, Committee And Council deferred
              action on this application containing three individual projects (see
              RM 00044  7/70.2) and recommended a site visit not only to study the
              projects but to review program development in  Maryland  since  it  received
              operational funds. The Chairman of the site  visit  team  reported  to  the
              Cbnmltt6e. the team's findings, which indicated  the  teamis  strong  feeling
              @that the "core" component needs a great deal  of  strengthening.  For  exam-
              ple,@the rapid turnover of staff And especially coordinators in the
              Mary and RNP was of major concern. Since  January  1967,  when  the  Region
              received its first planning award, there has been a total of four coordin-
              atoks (two of these being the same individual directing the program.
              The team learned that the present coordinator  planned  to  resign  effective
              June 30, 1970.
              Coupled with the concerts regarding core staff in  the  central  unit,  the
              site visit chairman related the outcome of the  teamts  mission  to  explore
              the intramural-extramural contribution made to the  Region  by  the  rather
              @large cadres of experts supported, in whole or in part, out  of  RMP  funds
              in   6 two medical schools and state health department.  He  went  on  to
              report that the team believed that to strengthen the core should ultimately
              lead to strengthening the Region.  Therefore,  the  visitors  recommended
               at the possibility that additional sums be made  available  to  the  new
              coordinator  administtativ6l    to  streng.then the  planning,  direction  and
                         $                y@
              p ofessi6hAl aspects of his immediate office be considered.  It was
              estimated that D6rhaps an additional $l5OiOOO  would  be  required-in  order
              to develop an effectively staffed central unit inladdition to the realign-
              ment of certain positions in the institutional cores.

              If the recommendations are a  proved, the central core  staff  budget  would
                                          @p
              be increased to a proximately $450,000 exclusive of approximately $240 000
                               p
              whi   is allocated to the epidemiology aiid@statistical center  of  Johns
              Hopkins.






             Maryland RMP                       2                  RM 00044'   7/70.1


             Project #28 -.Regional Oncology  Affiliation
             Critique: The Committee was advised that  this  was  a  proposal  stemming
                         out of a feasibility study which developed  an  oncology  affili-
             ation with  the Easton Hospital on the Eastern Shore of Maryland, an
             institution affiliated with Johns Hopkins. The  primary  objective  is  to
             ,extend the affiliation to include other small hospitals as a means of
             upgrading the knowledge of local practitioners.  The  Chairman  of  the  site
             visit team reported that the site visitors viewed@this  as  a  highly  service
             oriented program. seekin funds for a Program  which  should  already  be  an
                                      9
             ongoing part of the Johns Hopkins program.  The  visitors  could  see  little
             structure to the educational aspects of the  program.  Some  plans  were  set
             forth for periodic rounds, annual seminars  and  for  having  physicians
                't Johns Hopkins Hbsp'tal. A  tumor  registry  was  proposed  without
             visi                     I
             adequate investigation of the role of the tumor registries throughout
             the country. No determination has been made of  how  the  professional  fees
              collected would relate to this'project., The Review Committee was in agree-
              mdnt with the site visitors in  believing this to be an a  mo@t'-purely service-
             oriented program;  that it served no demonstration  purposes- did not  serve
                                                                         .1
             as a 'pilot project; 6r.have significant educational value.@

             The Review Committee adopted the recommendation of the site   visit   team
               at this proposal not be approved - revision  required,.  They  felt,that
             any revision should be recast to show the strengthening  of  the  affilia-
             @tion And educational aspects of the program. In  addition,  any  revision
             should contain concrete commitments that  cooperating  hospitals  are  actu-
             ally willin to develop affiliations and  the  budget  should  be  more  real
                         9                         5
             itically planned to defray the cost involved  in  the  educational  and
             demo stkationdl aspects of the program, rather than  in  the  service  aspects
             of the program..

             Recommendation:  Non-Approval II (revision required).


             Project #29 - A Cancer Detettion Program in Children

             Critique: Again, the Chairman of the site  visit  team  reported  findings
                         of the team about this project, the primary  objective  of  which
             is the early detection and diagnosis of malignancies during  -the  first  five
             years of life.

             The proposal would establish a training  program  for  physicians'  assistants
             to d tect solid tumors by'abdominal palpatdtion and  viewing  of  the  reflex
             of the retina in extraocular  movements.  Certain  lab  tests  would  also
             be i 6orpotated. Members of the Review  Committee  were  concerned,  as  were
             the site visitors,, with reference to:  (1) the depth of the physician
             assistants' ability to evaluate incidence; (2)  the  ability  to  maintain
             interest on the part Of examiners who do 'such routine work;  (3)  why  this
             6etvic6@wds not incorporated as a part-of'a  general  screening  program,,







              Maryland RNP                       3                    RM 00044  7/70.1


              and (4) lack of concern as to.what would be done for   the follow-up of
              detected cases.

              While the site visitors recommended that the proposal not be approved
              and that revision would be required, the Review  Committee  recommended  non-
             @approval with no RMP funding recommended. It was  the  opinion  of  Committee
              that the proposed activity be incorporated into one or several of the
              ongoing desertion programs which are currently funded in the Region.

              Recommendation:  Non-Approval I (no RMP funding recommended).


              Project #30   Continuing  Education  Program University of  Maryland  School
                            of Dentistry

              Critique:  The chairman of the site visit team reported to the Committee
                         that the proposers of this activity did not appear  at  the  time
              of the site visit.  The Review Committee noted that the application was
              in the form of a letter rather than in conventional form, and had insuf-
              f,16ient information upon which to make any 'udgment..

              Recommendation:  Non-Approval I (no RNP funds recommended).


                                    S@RY OF RECO@IKENDATIONS


                  ect
              Number        Title                        lst Year     Znd Year   3rd  Year

              #28      Regional Onc6logy Affiliation     Non-Apptoval II (revision required)

              #29      A Cancer Detection Program        Non-Approval I (no @ funds recom-
                       in Children                                        mended)

              #30      Continuing Education Program,     Non-Approval I (no RMP funds re 6m
                                                                                         c
                       University of Maryland School                      mended)
                       of Dentistry















                                                                         DRMP/GRB   7/13/70




             . 2















            0                                                              0                                                              0








                                         REGIONAL   MEDICAL   PROGRAMS    SERVICE
                            SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION
                                               (A    Privileged    Communication)

                   MARYLAND REGIONAI, MEDICAL PROGRA,,L             RM 00044 7/70.2
                   550 North Broadway                               February 1970 Review Committee
                   Baltimore, @l-aryland  21205                     March   1970   Council
                                                                    June 1970 R(!view Committee
                   PROC,@L COORDINATOR:  William S. Peeples,        @l. D.


                   @Lts-ttd-:             lst   Year         2nd   Year          3rd Year        TOTAL
                   Direct Costs:            $317,430           $154,651         $173,1.65       $645,246
                   Indirect Costs:            24,237             25,325             26,447         76,009


                   TOTAL                    $341,667           $179,976         $199,612        $721,255

                   History.   The  @larvland  Regional  Medical  Program   began   its   planning
                              in  January  1967.  Following  a  site  visit   and   a   Reference
                   Com-nittee of Council, an award of $1,932,883 (d.c.o.) was made
                   effective  March 1, 1969 for the Region to support core activities
                   ($724,360  d.c.o.) and operational projects ($1,208,533 d.c.o.).
                   The activities supported during this first operational year in-
                   cl@ide the following.  Direct costs only are noted.


                   IIROJEC-LS


                   CORE                                                          $724,360


                   ' I
                      - Continuing Educational Program for
                          Peninsula (,eneral Hospital                            17,550

                   L
                   ,@2 -Development and Evaluation of a Comprehensive
                          Technical Screening Program for School-age
                           Children of Low-income Families                       83,000

                      -  Early  Detection  of  Cardiac   and   Malignant   Disease
                          in   Pre-school   Children                             28,173

                   '@4 - A Program for Nlass Detection of Heart Disease
                          in School Children                                     24,448

                   #6  -  Early  Detection  of  Heart  Disease  in  the   Newborn 20,115

                   @17 - Coronary Care Program - Maryland University             78,000
                        Coronary Care Program - Baltimore City
                          Hospitals                                              24,362

                        Closed Chest Cardiopulmonary Resuscitation               38,240

                        Acute Stroke Unit                                       113,210
                        Cnronic Stroke Unit                                     110,438





                                                 2
            @LKRYL@D Regional Medical Program                     R@l 00044 . 7/70.2
                                                                          Requested
                                                                          First Year


             @e@ts       nti u@ed)
            #10 - Acute Intermediate and Long Term Stroke Care          146,412
            fall - Proposal on Stroke  -  University  of  Maryland      138,819
                  Proposal  on  Stroke  -  Rehabilitation  Nursing     45,252
                   Proposal on Stroke - Nursing Education Program      32,995

            #12  -  Proposed  Coordinated  Discharge  Planiing
                     Program for 14ico.-nico and Somerset Counties     16,579

            #13 -  Regional  Medical  Program  for  Outpatient
                     Strokes                                           39,509

            #14 - Demonstration and Training Program in the
                     Rehabilitation of Stroke Patients                  161,421

            @kl6 - An  Ambulatory  Program  for  Comprehensive
                  Pulmonary Services                                   90,000

                                                     T.')TAL         $1,932,883

           Approved but unfunded projects include Project iki9 and Project ik22
           which are to establish tissue typing laboratories.  These projects will
           be combined to reflect a combined Tissue Typing Service, listed as
           Project #19.                                                                 Requested
                                                                                       First Year
           Project ik25 -  Comprehensive  Stroke  Ero&Lam  -   Prince   Geor@!l
                          General Hospital.  This proposal  is for                      $209 704
           the establishment of a "Stroke- Center" at Prince George's
           General Hospital.  It will include the development of a cardio-
           vascular unit which  will  incorporate  the  latest  technology  for
           diagnosis and treatment, including rehabilitation an        ome care.
           The six-bed unit is to  be  set  up  and  equipped  with  electronic
           monitoring equipment.    One  of  the  immediate  objectives  is  to
           evaluate  the  effectiveness  of  this  equipment.  In  addition,  a
           fourteen-bed rehabilitation unit  will  be  located  within  a  100-
           bed extended care facility to serve when needed.      A  record  system
           will be set up for purposes  of  follow-up  and  evaluation  of  the
           proposed  program.  The  ultimate  objectives  are:  1)  integration
           of the  continuing  education  of  physicians  and  the  specialized
           training of allied health  personnel  with  a  combination  of  evalua-
           tion activities to find the  best  methods  of  achieving  the  desired
           results and  of  demonstrating  the  most  effective  patient  care;
           2) reduction in costs of  illnesses  in  which  care  is  traditionally
           fragmented;   and 3) preservation and restoration of the family.
           The educational facets of  the  proposal  include:  1)  training  of
           personnel who are to be manning the stroke center; 2) dissemina-
           tion of  information  or  methods  of  patient  care  to  practicing
           physicians and paramedical personnel;     3) family education con-
           cerning care and  rehabilitation  of  the  patient;  and  4)  public
           education with regard to cardiovascular disease.      Post-hospital
           care will be -nade available to  patients  by  Prince  George's  County
           Health Department, which has submitted for this review, Project #26
           Stroke Rehabilitation Program in the Home and in the Prince George's
           Co:jnty Health  Department  Rehabilitation  Clinic.






                                               3
                MARYLAND Regional Medical Program                       RM 00044  7/70.2
                                                                                  Requested
                                                                                  First Year


                The Stroke Committee will attempt to evaluate whether care in a
                stroke unit measurably affects the total recovery of the patient,
                reduces mortality or shortens the length of hospital  stay.  Data
                available through PAS will also be utilized and evaluated, as will
                the treatment patterns provided each stroke patient.
                The applicant does not specify how the program will be  Supported
                after the third year.
                Second Year:   $56,911             Third Year:  $71,390

                  Project -,k26 - Stroke Rehabilitation Pr@rarl in the     6 7
                               Home-and in the Prince @or@ills C  nt
                  Ilea tli_Lea@tment Rehabilitation Clinic.  The main objective
                  of this proposal is to provide a comprehensive reaimen of
                  post-hospital care for approximately 150 cerebrovascular
                  patients of Prince George's County.  This will be accom-
                  plished by:  1) setting up a coordinated comprehensive home
                  care program using physician consultants, public health
                  nurses, physical therapists, social workers and homemakers,
                  2) providing rehabilitation services at the Health Department
                  Rehabilitation Services Clinic.  Intermediate objectives include:
                  developing a coordinated program with Prince George's General
                  hospital to insure adequate liaison prior to discharge for cerebro-
                  vascular patients treated there, stressing the restorative aspects
                  of cerebrovascular disease with emphasis on family's responsibility
                  to the pati-ent and the need for continuity of care at the family
                  and professional level, and informing the medical profession of
                  the Health Department's role in follow-up care of the stroke
                  patient in a home care program of rehabilitation.
                  The Health Department will accept any patient referred to it by
                  the private physician or the hospital if the potential for rehabil-
                  itation exists.  Payments for home care services will be on a
                  sliding scale basis, with no charge for indigent patients.  No
                  information is provided as to how income from the project  will
                  be used.
                  A definitive evaluation of the stroke patient's progress will be
                  made and recorded to provide statistical documentation of the
                  effectiveness of early referral, treatment, and coordinated home

                  care.

                  Second Year:  $53,265            Third Year:  $55,800
                  Project @k27 - Llail@e e@nt of Intestinal Stomas.  The     $44,975
                                ultimate objective of this proposal is to
                  improve the management of ileostomy and colostomy patients
                  during preeperative,  immediate postoperative,  and during
                  I-                      T114c     lip qrrnmnlished by: 1) The






                                     4
         MARYLAND Regional Medical Programs                   RM 00044  7/70.2
                                                                    Requested
                                                                    First Year


         establishment of ostomy Clinics throughout the @laryland region
         which will provide inpatient consultations by a medical team,
         including physicians, enterostomal therapists, and social
         workers.  The team will respond to consultation requests and
         will observe differences, and compare results of approaches and
         choice of appliances.  This aspect of the program will initially
         involve 3 or 4 liz)spitals in Baltimore and several outside the
         cit%,; 2) Professional and public education programs consisting of
         lectures and seminars held at neighboring hospitals for physicians,
         nurses and allied health personnel, and at Osto,-ny Clubs and other
         la%@ groups; 3) Training physicians, nurses and psychologists
         in the management of ileostomy and colostomy patients.; 4)
         Estal)lishing sources of aid for the patient by means of regional
         Osto-nN, Clinics, Ostomy Clubs, and a system for consultations
         with community physicians and hospitals throughout the  region;
         and 5) Evaluating the nature and extent of problems facing  the
         ileosto-ny and colostomy patient from the noint of view of
         epidemiology, psychologic adjustment, interpersonal relation-
         ships, physiologic response, postoperative recovery and appliance
         difficulties.


         The program will investigate the many problems facing   the
         ileostomy/colostomy patient and will attempt to devise a  means
         of evaluating the comparative benefits of consultations by  the
         medical teams, enterostominal therapists and fellow  ostomates.

         Second Year:  $44,475            Third Year:  $45,975

         Review Committee Critique - February 25-26, 1970


         GENERAL:  The Committee recommended that this supplemental
                   operational application for a three-year program
         period be partially funded at $135,425 (DCO) to support
         Project #27 in the time and amount requested; also, that
         action on Projects #25 and #26 be deferred perding a site
         visit.  The last site visit to the Region was conducted on
         Dccember 11-12, 1968.
         The Review Committee was concerned over the size of the Core
         Staff supported in the Maryland Region and with the
         obvious lack of intramural-extramural contribution' by this
         cadre of experts to the preparation of the supplemental
         operational application.








                                               5

                MARYLAND Regional Medical Program                          RM 00044  7/70.2



                Council - March 1970:  The Council concurred with Review Committee's
                                       recommendation with the exception of Project #27.
                and asked that it be deferred also for a site visit.  The Council
                asked that the site visitors further assess the merit of this project (#27)
                without the film component.  They question the value of teaching films
                for these patients or for physicians and allied  health personnel who
                work with them, principally because of the great variation in the physical
                and emotional characteristics of the individual patients and the great
                variety of surgical procedures resulting in the stoma.

                Site Visit:  A site visit was made to this region on May 21-22, 1970,
                            and a report will be available to the Review Committee.






                                                           (A Privileged Communication)


                                 SUM%RY OF REVIEW AND CONCLIISION OF
                                 JUNE 1970 REVIEW COMMITTEE


                                 MARYLAND REGIONAL MEDICAL PROGRAM
                                         RH 00044 7 70.2


                         FOR CONSIDERATION BY JULY 1970 ADVISORY COTYNCIL

          General:  The Review Committee recommended that this supplemental operational
                    application, containing three individual projects and requesting
          $645,746 d.c o., for a three-year program period, be  partially  funded  at
          $385,425 - t; support Project #25 in the time and for a lesser amount than
          requested (Project #26 is merged with Project #75) and to fund Project #?7 in
          the time and amount requested.

          During the February/March 1970 review cycle, this entire application (then
          containing four individual projects) was reviewed with the following
          recommendations:

            Project #24 - Position of Director of Continuing Medical Education
                          Anne Arundel General Hospital    Nonapproval; return for revision.

            Project #?5  -Comprehensive Stroke Program    Prince Georke's Ceneral
                          Hospital - Deferral to include a site visit.

            Project #26  -Stroke Rehabilitation Program in the Home and in the
  10                      Prince Ceorge's County Health Department Rehabilitation
                          Clinic - Deferral to include a site visit.

            Project #?7  -Manapement of Intestinal Stomas - Approval in time and amount
                          requested by Committee L-def-er-Fal to include a site visit by
                           Council.
          The site visit was conducted,on May 11-12, 1970.  The Chairman of the team
          presented the findings to the Committee.

          Project #75 - Comprehensive Stroke Program - Prince Ceorge's General Hospital.
             and
          Project #26 - Stroke Rehabilitation Program in the Home and  in  the  Princt
                        Ceoige's County Health Department Rehabilitation Clinic.

          Critique: The Chairman of the site visit team advised  the  Committee  that
                    because of the complementary purposes of these two proposals
          eplus the actual physical locations of the applicant agencies), the site
          visitors considered them as a single proposal.  It was noted that the
          applications had been in the process of development for over two years.  The..
          overriding concern of the visitors was that the applicants had  been  given
          erroneous information and were not really aware of the general types of
          programs which Regional Medical Programs Service supports.

          AccordinR to the site visitors, this was a sincere and dedicated  group  of
          people @@o were deeply concerned that stroke patients in their area were not
          receiving adequate care.  These proposals envision a complete stroke service,





        MARYIAND Regional Medical Program            - 2 -            RM 00044  7/70.2

                                                                    ile    followup-
        the acute phase being handled in the general hospital wh
        rehabilitation service is to be handled in the County Health Department.
        Approximately 25 stroke cases are now handled annually.  The applicants
        estimate that this-total may be increased to 100 stroke cases per year,       if
        these requests are approved and funded.
        The major weakness of the proposal was    the lack of planning for the educational
        phase of the proposal.
        The Review Committee agreed with the site  visitors  that  there  was  a  need  to
        fund this activity to some extent.  This would serve two purposes.  It would
        emphasize the momentum that has been gained as it pertains to regionaliza-
        tion and would avoid prejudicing this large group of people against any
        future RMP activities.  Further,  the  Committee  believed  that  this  group  was
        obviously not in a position to utilize all of the facilities that they
        requested and that some future planning activity (along with some demonstration
        activities) Aare in order. It  was  believed  that  the  emphasis  at  this  time,
        should be on developing more adequate educational techniques and emphasizing
        the physical therapy care of the  patient  beyond  the  acute  stroke  phase,  and
        its relationship to home care and home-care planning.
        In recommending approval, the Review Committee, in line with the recommenda-
        tions of the site visitors, believed  that  funding  of  this  project  should  be
        mainly for personnel who  could  initiate  the  home-care  phases,  and  for
        such additional professional time as may be necessary for more adequate
        planning of the educational phase.
        The Review  Committee  concurred  with  the  specific  direct  cost  funding
        recommendations of the site visit team which were:

                       Refs Countv Health Department
             Personne
              Full-time physical therapist                                 $   9,189
               Full-time occupational therapist                              9,189
               Half-time secretary                                           2,700
               Full-time homemaker                                           4   800
                                                     TOTAL    PERSONNEL    $25,878
                 lies                                                        1,400
             Consultant Services                                                 500
             Other (Mileage)                                                 1   400
                                          TOTAL    HEALTH DEPARTMENT       $29,178

           Prince Ceorge's General Hospital
             Personnel
               107. time - Project Director                                  5   ?00
               15% time - Physiatrist                                        5:200
               Full-time Rehabilitation nurse                                 10,400
                                                   TOTAL - HOSPITAL        $70,800
              FIRST   YE                       PROJECTS  -                 $49,978
                       -AR TOTAL FOR COMBINED







         YARYIAND Regional Medic  i,                                     RM 00044 7/70.2

         Again, Committee followe@  the i               of time site visit team that
         support for the second and third years be increased to provide additional
         funds for personnel, if Justified by the progress made during the first year.

         Recommendation.-  Approval for, a three-year period in amounts as listed above.

         Direct Costs Onlv:        lst,Year      2ild Year    3rd Year
                                   $50,000       $100,,Ooo    @ioo,ooo

         Project #27 -       enw-rnt of Intestinal Stomas.

         Clitaue,.  During the February/March 1976 review cycle, the Committee
                    recommended approval of this project t'n time and amount requested,
         while the Council recommended deferral for review by members of the site visit
         team.  Councille primary concern was the value of providing teaching films for
         atoms patients or for physicians and allied health personnel who work with
         them, principally because of the great variation in the physical and emotional
         characteristics of the individual patients and the great variety of surgical
         procedures resulting in the stoma.  The site visit team Chairman advised the
         Committee that the t"m'a mission was believed to be fact finding rather than
         review of the concepts of this proposal.

         Questions were raised with reference to producing films, pbasing out the project,
         and the establishment of a registry.  The site visitors were advised that-

           1) The registry has been deleted.
           2) Phasing out is entirely conceivable, with the cost of this service to be
              included as a legitimate hospital cost.  Cliriies of this type are a
         recognized part of hospital services.  Funds requested in this proposal would
         be in referents to the educational aspects but this could be done incidental
         to the training of additional technicians andit therefore, the project would
         be self@6upporting after the withdrawal of W funds.
           3) The project proposers made a strong case for the support of films which
              they felt would be the heart of the program.

         While the applicant agreed that some material is presently available from
         medical supply houses and device manufacturers, the films etc. were considered
         biased toward the product of the individual concern.  Plans in this proposal
         include development of suitable films for showing to patients, both pre-
         operatively and postoperatively.  They also plan films which would be
         instructional for physicians.

         The Chairman emphasized the applicant's statement that the films were not
         to be used out of context.  Rather the films are to be used to refresh and
         reinforce the instructions provided in person by the physician, therapist,
         and technician.  The Review Committee was further advised that an additional
         film it planned, aimed at teaching physicians some of the principles required
         of them in dealing with patients.  Again, this is thought to be less
         technical and simply reinforcing to physicians of their role in the prep&-
         ration of patients and in the support of patients following such procedures.





       MARYIM Regional Medical Program                - 4            RM 00044 7/70.7
       Committee noted the low costs of the films  when  compared  to  the  usual  costs
       of production.
       In recommending approval, the Committee concurred with the site visit team
       that this is a legitimate request which should  be  supported  in  the  time  and
       amount requested.
       Recommendation:  Approval in the time and amount tequest6d.
       Direct Costs Only:       lat Year       2nd Year       3rd Year
                                $44,975        $44,475        $45,975








                               SUMMARY OF RECOMODAT IONS


       Project
       Nrimber  Title                                lat Year     ?nd Year      3rd Year
       75-26   Comprehensive Stroke Program -       $50,000      $100,000       $ioo,ooo
               Prince George's General Hospital
               and County Health Department
       77      Management of Intestinal Stomas       44,975        44,475         45,975
                                   TOTALS  -        $94,975      $144,475       $145,975

       Year                                         Total Direct Costs
       01)                                        $ 94,915
       02)                                         144,475
       03)                                         145-,975
                                                  $385,425





                                                                 DRNPIGRB 7/13/70





                                                       A PRIVILEGED COMMICATION
                                                       RM 00044


                                 SITE VISIT REPORT
                        MARYLAND REGIONAL MEDICAL PROGRAM

                                  may 11-12, 1970
       LIST OF PERSONS ATTENDING             MEETING  BY I          IATION

       SITE VISITORS
       Philip T. White, M.D. (Chairman), Member of RMPS Review Committee
         Professor and Chairman, Department of Neurology
         Marquette University School of Medicine
         Milwaukee, Wisconsin
       J. Gordon Barrow, M.D.
         Program Director, Georgia Regional Medical Program
         Medical Association of Georgia
         938 Peachtree Street
         Atlanta, Ceorgia
       William A. DeMaria, M.D.
         Assistant Dean, Continuing Medical Education
         Duke University School of Medicine
         Durham, North Carolina
         AFF  RECIONAL MEDICAL PROGRAMS SERVICE
  eMr. Robert Jones, Acting Chief, Programs Assistance Branch
       Mr. Joseph Jewell, Public Health Advisor, Grants Review Branch
       Mrs. Lorraine Kyttle, Staff Assistant, Grants Review Branch
       MARYLAND REGIONAL MEDICALL PPRROO(G;RRAAMM CORE STAFFS

          A. Central Unit
             William Peeples, M.D., Coordinator
             Mr. R.-ichard Metzinger, Business Manager
             Louis Hellman, Sc.D., Associate Coordinator for Evaluation
             Mr. Vern McMurrin


          B.
             Edward Stafford, M.D., Associate Coordinator
             J.D. Allred, Ph.D., Associate Coordinator for Medical Education
                 (Audiovisual
             B.E. Strem, Ph.D., Assistant Coordinator for Continuing Education
          C. Tnivers            land Administrative Unit
             Morton 1. Rapoport, M.D., Associate Coordinator
             Mr. Richard Peters, Assistant Coordinator for Administration
             William Spicer, M.D.
             *Robert Evans, M.D.


         *Dual listing





                                               2                        RM 00044
        MARYLAND RMP Site Visit
        MARYLAND REGIONAL 'MEDICAL PROIGRAM CORE STAFFS (Continued)
          D. Maryland State Department of Health Administrative Unit
              Perry Stearns, M.D., Associate Coordinator
              *Edward Davens, M.D.

              E           and Statistical Unit

              Abraham Lilienfeld, M.D., Director
              Maureen Henderson, M.D., Associate Director

        REGIONAL ADVISORY GROUP

        Mr. M. Shakman Katz, Chairman
        Alexander Dowling, M.D., Member
        Edith Schoenrich, M.D., Member
        COMMITTEES             REGIONAL MEDICAL PROGRAM

          A. Admin@.stratiiie
                   I
              John Moxley 3rd, M.D.  Dean, University of Maryland
              David Rogers, M.D. - Dean, Johns Hopkins University

             B.

              *Robert Evans, M.D., Chairman


             C. Heart Disease
              Leonard Scherlis, M.D., Chairman, University of Maryland
              Catherine Neill, M.D.
              Jerry Salan, M.D.
              Raymond Repner, M.D.

             D. Cancer

              Morris Wisenberg, M.D.


             E. Renal

              Edward Hinman, M.D.


             F. Stroke

              A. Earl Walker, M.D., Chairman

             G.

              *Edward Davens, M.D.


         *Dual listing




       MAR'NAND RMP Site Visit                 - 3 -                      RM 00044

       OPERATIONAL PROJECTS (Ongoing)
       Erland Nelson, M.D., Stroke Project Directors University of Maryland
       Mrs. Ann Harvey, R.N., S@roke Project, University of Maryland
       Thomas Price, M.D., Stroke Project, University of Maryland
       John Cessner, M.D., Stroke Project Director, Montebello State Hospital
       OPERATIONAL PROPOSALS (Deferred pending site visit)
         A. #25 and #26 - Comorehensive Stroke Progr4m - Prince Ge6rge's County
                           General Hospital and Health Department

             Ruth 1-@lacoby, M.D.
             Benjamin Strickland, M.D.
             Doctors Steinman and Stazid
             Messrs. Parker, Robards and Penn
             Mrs. Devlin, R.P.T.

          B. #27 - Management of Intestinal Stomas

             Marvin Shuster, M.D.
             Mrs. Charlotte Blackman@ Enterostomal Therapist
        NEW SUPPLEMENTAL OPERATIONAL PROPOSALS (To be considered during June/July 1970
                                                 review cycle)

          A. #28 - Regional Oncology Affiliation

             Raymond Lenhard Jr., M.D.
          B. #29 - Cancer Detection Program in Children

             William Zinkham, M.D.







                                                                        Rm oOO44
        MARYLAND RMP Site Visit               4
           oses of the Site Visit. -This site visit served a dual purpose.  Staff,
                                    during.its February 9, 1970 review of the non-
        competing continuation application (Type V), made the following recommendation
        to the Deputy Director:  "-- that a program site visit be scheduled in early
        June 1970, with a member of Committee, of Council, and of RMPS Staff, to
        explore the interrelationships of the Core staffs with projects, as well as
        the degree of coordination among the various Core components       This
        recommendation and the other recommendations made during the review, were
        accepted by the Deputy Director on February 20, 1970.
        During the February/March 1970 review of a supplemental operational
        application which requested support for four new operational proposals,
        the reviewers expressed concern over the size of the Core staffs supported
        in the Maryland Region and the obvious lack of intramural-extramural
        contribution by this cadre of experts to the preparation of all the
        supplemental operational applications submitted by this Region to date.
        The March 1970 Council recommended that a site visit be conducted on the
        four proposals (three of which were deferred pending the visit, while the
        remaining proposal was recommended for "nonapproval - revision required").
        In addition, the site visit would provide opportunity for both Staff and
        a Committee member to seek information relative to the viability of the
        Region.  The last site visit (preoperational) to the Region was conducted
        during December 1968.
          kground of Maryland RMP.  The Maryland Regional Medical Program encompasses
        Bac
                                     the State of Maryland (with the exception of
        Montgomery County, which is one of the large counties adjacent to the
        District of Columbia), and includes York County, Pennsylvania.  Approximately three
        and one-half million people live within the Region's 9,874 square miles.
        73% of the population is considered urban and 83% Caucasian.
        The Region contains two large medical schools - John@ Hopkins University
        School of Medicine (enrollment 350) and the University of Maryland School
        of Medicine (enrollment 367).
        !'here are 13 schools of nursing, two of which are university based.  As of
        1965, there was a total of 86 hospitals with 33,366 beds - 18,796 of which
        are nonfederal, long-term.  Also, during 1965 there were 5,450 medical
        doctors, 2,946 of whom were in private practice. The Region  has  20
        osteopathic physicians.
        One of the overriding concerns of Staff and the review groups has been
        the rapid turnover of coordinators within the Region.  During January 1967
        the Region received its first planning award - Coordinator, l@Tilliam J. Peeples,M.D.
        During March 1967, Thomas Turner, M.D. was appointed as Program Coordinator.
        During January 1968, William S. Spicer, M.D. was appointed as Acting
        Coordinator of Maryland RMP. Following this, during  November  1969,
        William J. Peeples, M.D. was again appointed as Coordinator.





                                                                      RM 00044
         MARYL&ND RNP Site Visit           - 5 -
         t the time of the site@visit it was alleged that the coordinator's
         position was soon to become vacant again.  This was privately confirmed
  lwby the present coordinator to two of the professional site visitors.
         Then too, the deans of the medical schools alluded to an imminent change
         in program directorship.
         Regional Advisory ou  and Committees.  The Maryland Regional Advisory
                                                Group is composed of 27 members
           M.D.s) and, of this total, only two members are considered to be
         from outside the Metropolitan Baltimore area.  Two members of the group
         are black.  The chairman is Mr. M. Shakman Katz.
         The Region may be considered a bit unusual in that this group meets
         ten times per year instead of quarterly.  In spite of the frequent meetings,
         it was reported to the site visitors that an average of 17 members present
         is normal for each meeting.  The chairman also advised the team that, in
         general, the Regional Advisory Group reviewed only those applications
         which were positive from other review committees within the Region.
         There are plans to expand the membership of the RAG  - from the present
         27 members to 33 voting members.  When this new organization is effected,
         one-third of the membership shall be terminated each year.  Membership
         to the RAG may be nominated by the RAG or the coordinator, subject to
         approval by the Administrative Committee.
         Administr          ttee.  This committee is.composed of the
                                    following ex officio members:  Deans of the
         two medical schools; Commissioner of Health; Dean, Johns Hopkins School of
         Hygiene; Coordinator of RMP; and Chairman of the RAG (without vote).
         The functions of the committee are to:  1) appoint the coordinator;
         2) make final decisions on all administrative matters; 3) appoint members
         of RAG; and 4) establish policy for administrative operation.
         0 her Committees.  The Region has seven Categorical Committees:  Heart,
                            Stroke, Cancer, Epidemiology and Statistics, Continuing
         Education, Kidney, and Pulmonary.
         Site Visit Team Findin s-  The site visit team requested that the agenda
                                    begin with discussions of the committee structure,
         administrative channels, the,review process, and a program overview by the
         Central core, the institutional Associate Coordinators and the committee
         chairmen.  Dr. Peeples opened the meeting with a presentation of the
         committee structure and its relationship to the central staff.





                                                                   Rm 00044
        mARYIAND RMP Site Visit
        It a.s the consensus of the site visitors that the Regional Medical Program
         w                     nd grown largely through the strengths that pre-
        in Maryland had evolved 8                                              -A
        existed in the two medical schools.  Even though the arrangement account@-
        for a several-horned structure including the central Core, the two medical
        schools, an Epidemiology and Statistics Unit and the State Health Devartment
        Unit, the real strengths still lie in the two medical schools.  This was
        emphasized by the role of the Administrative Committee (whose membership
        included the two deans), the Categorical Committee (the membership of@which was,
        largely composed of the two medical school faculties), the emphasis on con-
        tinuing education (which was really a prolongation of a preexisting relation-
        ship between Dr. Evans, Chairman, Continuing Education Committee, and the
        University of Maryland), and the relatively passive role of the Regional
        Advisory Group (which tends to accept the decisions.and the judgments of the
        Administrative Committee and the Categorical Committees.)
        it immediately became apparent that there are too few full-time people on
        the central Core staff and that they have found it difficult to guide or
        counteract the strengths of the schools.  It was the feeling of the site
        visitors that a definite effort should be made to strengthen the central
        Core, not in an attempt to subjugate the schools per se or to destroy their
        roles in the creation of more programs, but to help give the schools  directions
        which may be something other than the traditional ones the schools'usually take.
        Some recognition of this apparently existed on the part of the Region.
        ,Mr. Katz, the Chairman of the Regional Advisory Group, expressed a  recognition
        of the fact that this group needed to be enlarged to give additional repre-
        sentation to non-Baltimore-oriented members and to minority groups.  He  further
        recognized that the programs and projects of the Region to date had largely
        grown through preexisting interests and activities in the medical school, and
        had taken steps to appoint a hopefully active committee on planning and to
        establish a system of priorities.  Further,each of the categorical committees
        had recognized the need for additional planning and were creating subcommittees.
        It was somewhat distressing to note that there was apparently no recognition
        of the need for the various subcommittees of the categorical committees to
        relate in some way to the Planning and Priority Committee of the Regional
        Advisory Group.
        The team also recognized that the associate coordinators at Hopkins and
        University of Maryland (whose time or effort and corresponding RKP salary is
        listed in the budget as 50% and 85% respectively) have a tendency to identify
        with the medical schools with whom they have an academic affiliation, rather
        than with the Regional Medical Program office.  In view of this the site
        visitors would recommend, in addition to strengthening the staffing of the
        central Core, that the medical school associate coordinators have full-time
        appointments as Regional Medical Program employees.  This recommendation is
        viewed as a necessary administrative adjustment so that the  institutional  core
        staf.fs would clearly relate to a central core Regional Medical Program  associ-
        ate coordinator.  Emphasis should be made here that minority groups do not
        seem to be represented, not only on the Regional Advisory Group, but within
        the administrative central structure of the Regional Medical Program.



          MARYIAND RMP Site Visit              -7-                    RM 00044
          There was also concern expressed  about  the  avenues  that  had  been  establish
                                                                                          ed
          for  the  various  associate  coordinators  and  assistant  coordinators  meeting
          from time to time to  discuss  mutual  regional  problems  and  concerns.  Formal
          communications have been established but there  was  some  confusion  as  to  how
          frequently these meetings are held.
          Dr.  Hellman,  Associate  Coordinator  for  Evaluation-Central  Staff,  discussed
          some of the efforts he was making as a representative of Core staff to
          encourage community  participation  and  regionalization.  He  discussed  the
          efforts that were being made to hold seminars  in  reference  to  home  care
          programs.
          Re pointed out that he had jaunted  through  the  Region  at  least  once  during
          his employment with RMP.  He apparently had visited somewhere around 30-plus
          out of a possible 40-plus hospitals  (with  100  beds  or  over)  that  exist  in
          the State. It was not quite certain whom  he  had  contacted  or  what  had  been
          accomplished by these meetings. He  was  making  a  sincere  effort  to  acquaint
          them with the Regional Medical Program and its role.  He was more than willing
          to agree that his efforts had  been  somewhat  limited  and  that  probably  more
          concerted effort was needed along these lines.  At this point it was discussed
          by the site visitors whether or not there might  be  a  need  for  some  type  of
          subregionalization, the appointment  of  area  coordinators,  or  some  other
          mechanism  which  would  help  develop  closer  relationships  with  communities,
          physicians, the public, and hospitals rather than just itinerant travelling.
          (.Questions were asked as to what relationships had been established with other
          health agencies.  Little was offered except that not too close a relationship
          with Comprehensive Health  Planning  existed  except  possibly  in  reference  to
          data'collection.  Apparently  community  health  planners  are  cognizant  of
          Dr. Lilienfeld and Dr. Henderson's  expertise  along  these  lines  and  are
          perfectly willing  to  cooperate  in  this  regard.  The  visitors  were  advised
          that the development of interlocking  efforts  with  CHP  weVe  difficult  to
          establish because of the relatively  weak  CHP  structure  in  this  region.
          Dr. Stearns presented the viewpoint of  the  State  Health  Department  as  a
          part-time coordinator assigned  to  that  department.  (The  budget  for  the
          upcoming year requests  a  100%  State  Health  Department  Coordinator.)  He
          emphasized that the State Health Departmentis concerns had been in reference
          to the involvement of small  hospitals  in  the  development  of  preventive
          programs.  Dr. Heilman's efforts in this area apparently were reinforcing to
          Dr. Stearns' role because other  priorities  had  been  placed  on  Dr.  Stearns'
          time by the Health Department.  Dr.  Stearns  commented  that  he  had  acted  as
          1'referee" early in the course of the development of this program, injecting
          himself between the two medical schools  but  that  this  seemed  to  be  abating
          as time passed.  He seemed to indicate that there was now a greater atmosphere
          of cooperation and acceptance between the two schools.
          Dr. Stafford represented the viewpoints of the associate coordinator for Johns
          Hopkins University.  He reaffirmed that there were discourses occurring between
          the  two  medical  schools  and  their  respective  associate  coordinators.  His
          comments were reinforced by  those  of  Dr.  Strem,  (Assistant  Coordinator  for
          Continuing  Education),  a  full-time  employee  of  Regional  Medical   Programs
   0      assigned to  Johns  Hopkins.  Dr.  Strem  emphasized  the  activities  that  were




       MARYLAND RNP Site Visit               -8-                   RM 00044
       ongoing on the part of Hopkins to create an atmosphere of learning and
       education at community hospitals and their complete agreement to cooperate
       with the development of directors of continuing education in an atmosphere
       which would enhance education.  Dr. Strem has been active in establishing
       seminars to teach how to teach, - in.establishment of guidelines for
       educators; in the establishment of guidelines for library resources; in
       helping local hospital libraries to assess their resources and service.-.
       Further reinforcement was added by Dr. Allred, (Assistant Coordinator (50%),
       Hopkins, an expert in the field of audiovisual assistance, who emphasized that
       they were holding continuing workshops on the utilization of audiovi  sual materials
       and of their instructional technology. The  visitors  were  impressed  with  this
       manIs sincerity and his efforts to reach out into many areas of the Region,
       lending his expertise freely and openly.
       Dr. Allred commented that he was working  with Dr. Neill in developing self-
       instructional materials in conjunction with Prcject  #6  on  the  Mass  Detection
                                 ew@orn
       of Heart Disease in the_Newborn.  He, too, is working closely   with local
       libraries to help them develop their resources and teaching aids.
       The University of Maryland Unit was represented by Dr. Rapoport, Associate
       Coordinator, reaffirming that affiliations do exist, particularly in the
       fiel(I of continuing education.  Dr. Spicer, former RMP coordinator and recently
       appointed Associate Dean for Health Care Programs, University of Maryland,
       emphasized the commitment that was made by the University of Maryland to
       ('.c,velop a truly reasonable health care system incorporating  outreaching  into
       the community both from a standpoint of  health  care  and  educational  systems,
       and that. he envisioned the Regional Medical Programs  as  having  a  significant
       role to pla in this regard. As a part  of  this,  plans  were  envisioned  whereby
                  y
       medical students could actually obtain part of their training and teaching
       at the community hospitals. Hopefully,  this  might  add  ramifications  for  the
       future. Dr. Spicer reaffirmed that in essence  they  were  trying  to  develop  a
       more appropriate system for the delivery of care and education, utilizing
       communities and community hospitals and practitioners,  and  that  there  was  no
       primary concern whether the relationships  were  with  Johns  Hopkins  University
       or the University of Maryland.
       Dr. Robert Evans, (Chairman, Continuing Education Committee), outlined the
       experiences at York, Pennsylvania Hospital and indicated  he  was  convinced  that
       community education programs were of value as measured by changes in the
       medical structure in York, as measured by there being more doctors who were
       better educated and who were more active. It was  his  feeling  that  health  care
       had been improved thereby. He further felt that  this  could  serve  as  a  model
       for regionalization throughout Maryland.
       Dr. Evans then continued as a representative of the Region's Committee on
       Continuing Education. He affirmed that their  view  on  continuing  education  was
       cl6sely:related to an emphasis on peer review,  medical  audits,  self-review  and
       thereby the identification of needs for further education and training.



         MARYTAND RMP Site Visit               -9-                 RM 00044
         A report was made by the Epidemiology and Statistics Committee.  It should
         be recognized that Dr. Lilienfeld and Dr. Henderson are an integral part of
         the Epidemiology and Statistics Center at Johns Hopkins.- The Committee
         therefore functions by advising itself.  They have also recognized that
         they now must begin functioning in the evaluation of the region's projects.
         Currently, they review each of the projects submitted in reference to
         methodology, budget, etc.  In addition, they will, in the very near future
         at least, begin functioning by structuring evaluation procedures which are
         to be built into each project.  They indicated that they will now write out
         a de-@ailed method of (!valuation for the consideration of each project  director.
         However, both physicians expressed the concern that there is still a lack of
         certain data in the Region which, if available, would help them create realistic
         evaluation procedures.
         Dr. Lilienfeld indicated that they were now on the verge of being able to
         demonstrate some of the characteristics of the Region based on the data that
         they were accumulating from hospitals, nursing homes, outpatient facilities
         and that the obtaining of the data would assist them to establish a baseline
         of regional characteristics and a further base for  the  establishment  of  evalu-
         ation procedures.  Dr. Lilienfeld stated that they recognize the need to re-
         evaluate periodically to identify changes  in  disease,  interpersonal  relation-
         ships, care availability, etc. They hoped  that  this  would  eventually  lead  ,
         tIo their being able to identify that the Regional  Medical  Programs  had  had  an
         impact on this Region.
                             I
         T@,.@ Epidemiology and Statistical Unit has encountered certain delays in the
         @@@c@,velopment of their program due to the shortage of qualified people. A  point
         was made here that funding uncertainties of the Regional Medical Program
         appeared to have hurt their recruiting efforts.
         The team was somewhat concerned as to the amount of monetary support required for
         this sort of activity. ($239,000 direct costs  are  budgeted  for  this  activity
         in the current year.)  It was clearly recognized, however, that there were
         sources of expertise here which did not exist in may areas of the country.
         Further,. these individuals were capable of training others to really accumulate
         and collate very reliable data.  It was agreed that these people are on the
         verge of making some significant statements with reference to incidence of
         prevalence of disease, health care patterns, etc.  Further,  it  should  also  be
         viewed that this is probably not just purely local data but  some  of  the  infor-
         mation gathered would be pertinent to many Reg,ionp, throughout the country.  The
         team believed that this is more than just a simple data collecting center.  They
         recognize the need for studying relationships between hospitals, physicians,
         individuals, medical students and all persons involved in the delivery of health

         care.
         Dr. Earl Walker reported as Chairman of the Stroke Committee.    He gave a progress
         report on the various stroke projects that were  ongoing.  He  related  that  the
         Deer's Head project for outpatient rehabilitation was under  way  and  had  picked
         up in activity since the end of the year.  The program at the Johns Hopkins
         Hospital and the Baltimore City Hospital had not been initiated because of
         difficulties in the recruitment of appropriate personnel  as  well  as  remodeling
         of areas.  The Peninsula General Hospital program was not completely staffed
         and had been recommended for continuation without additional funds.  The



         MARYIANI@ FM Site Vist             -10-                RM 00044
         program at the Sinai Hospital was well under way with a number of patients
         having been reviewed, treated and incorporated into fairly active teaching
         programs.  The program at York Hospital was well under way with 323 patients
         having been monitored and 2732 of these fitting into the stroke category.  Some
         early data from this study suggested that there was a higher than 6xpected re-
         lationship between the stroke patient and cardiac conditions,namely arrhythmias.
         Dr. Walker then spoke of the program at the University of Maryland indicating
         that a fairly active outpatient program had been initiated but that the in-
         patient program was still awaiting the completion of purchase of equipment and
         renovations.  The related program at Montebello State Hospital was active,
         both in the care of patients and in the sphere of training of nurse students
         in rehabilitation techniques.  They have also begun to recognize the need for
         admitting relatively acute but fairly stable strokes to the rehabilitation
         program early.
         Mrs. Anne Harvey, R.N., related the progress that has been made in holding
         nurse workshops.
         The site visitors were concerned after this review because while some of these
         projects were showing reasonably satisfactory progress, there seemed to be
         little concern on the part of the committee for developing interrelationships
         between these various programs as, for exampl6, in the dxchange of personnel
         or the training of personnel groups which might be applicable to one of the
         other programs.
         The Heart Program Committee activities were presented by Dr. Leonard Scherlis.
         The site visitors felt a similar concern that while a number of fairly worth-
         while projects were ongoing, there again appeared to be little interplay
         between them.  Dr. Hepner reported on the progress of the phonocardioscan
         programs.  It was recognized by him that this was only a minor part of the
         program and that screening programs of this sort should in reality tend to
         the uncovering of a multitude of diseases rather than just simply an emphasis
         on phonocardio scanning.  He did indicate that about 3,000 children had been
         scanned so far with more disease being found than they had anticipated.
         The site visitors were advised that the Heart Disease in the Newborn Project
         which is apparently not entirely operational appears to be moving along
         reasonably satisfactorily.
         Dr. Scherlis reported on the progress that had been made in the cardiopulmonary
         resuscitation program.  He reemphasized his concerns as to the absence of a
         suitable vehicle for transporting the educational apparatus from site to site.
         Staff had recommended that no funds be spent for either rental or purchase of
         a car.  He asked that this be given serious reconsideration.  Some of the
         site visitors felt that there might be some merit in his request for such a
         vehicle.  The site visitors would not feel averse to approving purchase or
         rental of a vehicle if no additional funds are needed beyond those which are
         already budgeted.
         Dr. Scherlis then reported on the progress of the coronary care unit programs.
         This appears to be a rather traditional educational program for nurses and
         physicians that did not significantly differ from a number of programs in a
         number of other Regions.




          mAKiL"Nu @nP Site VISIL                                     rwi VVV-*@
          The next report was by Dr. Eisenberg in reference to the activities of the
          Cancer Committee.  They apparently have identified four areas of concern
          wliit-@ti: 1) related to the establishment of a registry; 2) to the creation of
          a network of clinics with appropriate affiliations with medical centers;
          3) development of a regional blood bank system; and 4) the establishment of a
          community uterine cancer control program.  It was noted that this latter
          program was probably going to be picked up by the State  Board  of  Health.  He
          indicated that the Cancer Committee had been the last to  submit  projects  but
          that some were now being submitted and considered.
          Pulmonary disease activities were elaborated by Dr. Davens.  He felt that the,
          coumii.tte had been active in identifying the scope of the problem and the utter
          lack of facilities to deal with it within the Region.  He indicated that this
          was a disease category of increasing proportions, currently accounting for
          the fourth greatest number of deaths in the State of Maryland.  The committee's
          goals had been identified as:  1) creating adequate ambulatory care facilities;
          and 2) developing adequate prevention programs.  Dr.  Davens  further  reported
          that it was the feeling of the committee that Dr. Spicer's project,
          Pro5zran, for Comorehensive Pulmonarv Services, was progressing properly and %gag
          beginning to demonstrate the need for more attention to chronic pulmonary
          diseases.
          Dr. Davens further commented on the educational programs that were being
          carried out in the public school system. He  felt  that  these  were  beginning
          to bear fruit in the sense that the youngsters  were  becoming  more  concerned
          @lbout the incidence of smoking. They, hopefully, were  also  going  to  become
          more community-conscious and be more demanding of their elders in the
          development of anti-pollution programs.
          Dr. Hinman reviewed the activities of the Renal Committee.  He indicated that
          the major efforts to this point had been directed toward identifying the needs
          for a more active transplant program, for the  development  of  more  adequate
          home dialysis facilities, and for establishing a  program  for  detection  and
          prevention of'the disease in its reversible state.  He indicated that no
          projects were ongoing at the present time but that a major grant request was
          in preparation, related to the training of personnel  and  the  development  of
          more adequate dialysis resources. Dr. Hinman made  a  point  of  stating  that
          he felt this committee had been instrumental in engendering cooperation
          between the institutions,,
          Dean Rogers and Dean Moxley reassured the site visitors that there was a
          good deal of desire on the part of each of them  to  regionalize  the  schools
          and their activities, and they viewed the Regional Medical Programs as being
          a significant instrument which could foster this.  They assured the team that
          there was A good working relationship between the two schools; that mistakes
          had  bIeen made in the past and that they hoped@to correct  these  so  that  pro-
          grams will not be duplicated but can interdigitate in a more meaningful
          fashion.
          They make a sincere effort to function well as part of the Administrative
          Committee.  The Deans believe the Administrative Committee to be a decision-
          making body which helped to resolve conflicts and make certain administrative




                                                 -12-            Rm 00044
         MARYLAND RMP Site Visit
         decisions but which really did not beak on the policies,  programs or
         projects of the Regional Medical-Program.  They, for example, do have an
         instrumental voice in the creation of search committees for new coordinators,
         and, apparently, they have recognized the need for the creation  of  such  a
         search committee at this time - anticipating a new coordinator in July 1970.
         Dr. Moxley made an interesting comment that upon his arrival  in  Maryland  he
         did not view Regional Medical Programs with any  great  degree  of  enthusiasm
         but that since being in this area, he had recognized the  role  such  programs
         could play and how this could really strengthen and complement medical school
         programs. They did emphasize, however, that as far  as  they  were  concerned,
         Regional Medical Programs was not a medical school program per se but a
         parallel program of equal strength and one with which they could work without
         conflict.
         Since this Regional Medical Program was originally funded  in  January  1967
         there has been a fairly rapid turnover of coordinators and central Core staff.
         Information developed during this visit suggests there will be further turnover
         not only of the coordinator but of some of the  central  staff  and  assistant
         coordinators as well.  The turnover may not be entirely without benefit.  Some
         egregious planning and fragmented operations of the past might be forestalled
         through personal consultation between the Acting Director of RMI?S and the new
         administration of this region.
         The site visitors would recommend that concerted efforts be made to strengthen
         the central Core of this program and that the new Coordinator have the opportu-
         nity to discuss with the Acting Director, RNPS,the possibility that additional
         sums could be made available to him,  administratively,  to  strengthen  the
         planning, direction and professional services aspects of his immediate office.
         It is estimated that perhaps an@additional $150,000  would  be  required  in order
         to develop an effectively staffed central unit in addition to the realignment
         of certain positions in the institutional cores and the rebudgeting of approxi-
         mately $40,000 from the institutional cores(where it is currently budgeted) to the
         central Core (for vacant positions).  These recommendations, the visitors calculate,
         would result in a central Core staff budget of approximately $450,000 (exclusive
         of the Epidemiology and Statistical Unit,,). Although the "Core" seems to be
         supported by a rather sizeable budget, a fair proportion of it is dedicated to
         the Epidemiology and Statistical Center ($239,092 direct costs) for the support
         of approximately 30 positions almost all of which are full-time people who are
         presently on board.
         Site Visit Team's Revi              als Review            ebruary/March  1-970
                                       R
         Project #24 - Position of Director of Conti
                       Anne Arundel Cener     Hospital                          iewed and
         recommended for nonapproval     return for revision.  It  was  not  considered
         during this site visit.
         Projects #25 and #26 - #25    Comprehen.sive Stroke ProRram, Prince Ceorge's
                                 General Ho         #26 - St
         Pr           e Home an                                                rtment
         Re              Clinic.  These tw4                                    deferral





           MARYI-.ANI) RMP Site Vis;.t           - 13 -                 RM 00044
   0       to incl-ude a site visit,  Because of their complementary  purpose  (plus
           the actual. physical locations of the Applicant agencies), the site visitors
           considered them as a  single  pro?osal.
           Quite a delegation from both the Prince Ceorge's  County  Hospital  and  the
           Health Department met with the site visitors.
           The general characteristics of the Region suggest that this is a
           principal hospital for Prince George's County.  According to the applicant,
           somewhere between 75%-80% of the County physicians are affiliated with
           this hospital. The hospital has  a  full-time  house  staff,  incorporating
           ten surgical residents, six medical residents, four OBCYN residents,
           three orthopedic residents, and fourteen interns.  Some of these are
           assigned to the neurostirgical service from time to  time.  Only  one  of
           this staff is not a foreign graduate.  The  administration  of  the  hospital
           seemed capable. There is an  apparent  recognition  on  the  administration's
           part of a need to upgrade the  institutions.  They  apparently  had  been
           misdirected in their, request for equipment, thinking  that  direct  support
           for equipment was available  from  RMP.
           it was obvious after talking to the delegation that this was a sincere and
           dedicated group of people who were deeply  concerned  that  stroke  patients
           in their area were not receiving adequate  care.  They  had  envisioned  this
           project as one which would help demonstrate to the physicians of that area
           what could be done for stroke patients,  given  adequate  facilities  and
           adequate knowledge. They had even gone ahead on  their  own  to  start  some
           initiation of the project. They had sent a nurse  to  Dr.  Rusk  for  special
           rehabilitation training. Also, they had  sent  an  x-ray  technician  to  a
           hospital in the District of Columbia  for  training  in  appropriate  x-ray
           techniques.  The visitors were advised that the hospital has already
           purchased $150,000 worth of special.  equipment.  In  addition,  they  have
           hired a full-time physiatrist and  apparently  made  some  physical  changes
           in the hospital so as to give him suitable space.  An extended-care
           facil.ity is, or wi.11 soon be, open and will have space dedicated to
           stroke patients.
           (An explanation is in order, and that is  that  these  applicants  had  not
           been given adequate guidance or instructions as  to  the  preparation  of  a
           project request and were not aware of the general types of programs which
           Regional Medical Programs Service supports.  The team interjected at this
           point that this simply reaffirms the strong  feeling  that  the  "Core"  in
           the Maryland Regional l,ledical Program needs a great deal of strengthening.
           This type of  project should not have been presented  to  site  visitors  in
           its present form.',)
           Dr. Benjamin Strickland and Mrs. Devlin,  R.P.1'.,  represented  the  County
           Ilealth Department's program in home care.  They viewed this as a
           continuation of the acute stroke program and,  in  reality,  would  like  to
           look upon t e two projects as one.  Mrs.  Devlin  and  Dr.  Steinman  had
           already developed communication (-z@iT-inels and were holding planning
           conferences so that str,ol@,es dismissed from the Prince ('eorge's  Hospital







                                                                    Em 00044
         MARYLAND RMP Site Visit              14
         were assured of ongoing care.  Mrs. Devlin estimated that in the last year
         approximately 25 such strokes had been referred to the Health Department,
         and they were anticipating that additional referrals would be made.  They
         would like to plan on handling approximately 100 referrals per year.
         In discussin  the educational aspects of the program, it became aopatent
                    9
         that the proposers had not really given thought as to concrete methods
         to be used in education. They had felt that simply having a demonstration
         project would acquaint the physicians and nurses and technicians in the
         hospitals with the value of such methods.  They had a vague concept that
         monthly meetings would be held and seminars presented.  No actually well-
         constructed program had evolved, however, in reference to physicians,
         nurses, or allied health people.  Nevertheless, the proposers did recognize
         this as'their responsibility and indicated their willingness to develop
         a more formal and well-constructed stroke teaching program in'conjunction
         with this project.
         The site visitors were impressed with the sincerity of this group.  They
         were also impressed by the fact that these people had been working on
         this project for well over two years and,as a result of being misinformed,
         had gone through a number of revisions and were on the verge of becoming
         somewhat discouraged.
         The administrative personnel of the hospital made a sincere plea to give
         them some directions and, hopefully, some funds to get this project at
         least'partially started. In the discussions that followed in reference
         to their request for equipment, it was apparent that they had misunderstood
         what kind of funding was available through RMP.  When some clarification of
         this was forthcoming, they indicated that they might well be able fo find
         the funds elsewhere for the purchase of at least high-priority equipment
         items necessary to this project.
         In' reviewing this project after the meeting, the site visitors were
         impressed with the need for funding this to some extent, to emphasize
         the regionalization, and to avoid prejudicing this particular group of
         people against any future RMP activities.  The site visitors felt that
         this group was obviously not in a position to utilize all of the facilities
         that they requested and that some further planning activity, along with
         some demonstration activities, were in order.  It was believed that the
         emphasis, therefore, at this time should be on developing more adequate
         educational techniques and emphasizing the physical therapy care of the
         patient beyond the acute stroke phase, and its relationship to home care
         and home care planning.
         Therefore, the team's recommendations are that funding of this project should
         be mainly for personnel which could initiate the home care phases, and
         such additional professional time as might be necessary for more
         adequately planning the educational phases.  Along with this, the team





                                               - i5                     Rm 00044
        14ARYLAND RMP Site Visit
        0                                  essary for certain supplies,   consultants,
        believed that support would be nec
        and travel.  Therefore, the recommended first-year budget would be at the
        level of $50,000.  In arriving at this total, the team recommended the
        following specific line items:

                                 v Health DeDartment

                                 Therapist -    $  9,189
              Full-time Occupational Therapist  -  9,189
              Half-time Secretary -                2,700
              Full-time Homemaker -               4  800
                  TOTAL - PERSONNEL              $25,878                    $25,878
                 ies                               1,400                      1,400
            Consultan  Services                      500                        500
            Other  Miles e                         1,400                      1.400
                                   TOTAL - HEALTH DEPARTMENT                 29,178

            prince Geor @ s General Hos ital
            Personnel
              107. Time  Project Director -     $  5,200
              157. Time  Physiatrist -             5,200
              Full-time Rehabilitation  Nurse  -  10.400
                      TOTAL - HOSPITAL           $20,800                    $20,800
              FIRST-YEAR TOTAL FOR COMBINED PROJECTS                        $49,978
           The site visit team also recommended that support be given  for the second
           and third years, with additional funds for  personnel,  as  justified  by
           the progress made during the first year. This  should  be  no  more  than
           twice the amount authorized for the first year.
           Project #27 - Management of     stinal_Stomas.  Although the February 1970
                        Review Committee recommei ed ap roval of this project in time
           and amount requested, the March 1970 Council  recommended  deferral  for
           review by members of the site visit team.  Members of Council asked that
           the site @.isitors further assess the merit of this project without the film
           component.',  They questioned the value of teaching films for stoma patients
           or for physicians and allied health personnel who work with them,
           principally because of the great variation in the physical and emotional
           characteristics of the individual patients and the great variety of surgical
           procedures resulting in the stoma.
           A brief review was held as to the nature of the project in general.  This
           was not gone into in depth inasmuch as the Review Committee and Council
           had both approved the general concept, and the only questions raised were
           in reference to producing films, phasing out the project and e tablishing
           a registry.  In reverse order, it should be commented that establishment
           of a registry has been deleted.





        MARYLAND RMP Site Visit             - 16 -                  RM 00044
        The team was assured that phasing out is entirely conceivable and that
        the costs for this program can be considered a legitimate hospital cost.
        Apparently, clinics of this sort are a recognized part of hospital
        services, and'technicians of this sort are legitimate employees of such
        clinics  The initial cost would be in reference to the educational aspects
        but tbi; could be done incidental to the training of such additional
        technicians and, therefore, the project would be self-supporting after
        the withdrawal of RNP funds.
        The project directors felt that films were at the heart of their program.
        They have planned on developing films which should be suitable for showing
        to patients, both preoperatively and postoperatively.  They were also
        planning films that would be instructional to physicians in the area.  It
        should be emphasized that the films ate not to be used out of context and
        will.only be used to refresh and reinforce the instructions provided in
        person by the therapist and technician.  The.Ifilms will be used to
        illustrate rather general principles, to provide psychological and moral
        support to.,the patient, and to reinforce the specific training provided
        by the technician and therapist.  These will be produced in the form of
        film strios which could be shown through-portable, automatic projectors.
        (The projectors were demonstrated.)
        Dr. Allred, Associate Coordinator of RNP (Audiovisual), is intimately
        involved in this project.  He and his staff will provide the expertise
        for the development of the appropriate script, pictorial material, and
        assembling of the film strip.  He estimates that the total cost for a
        master and two or three copies would be somewhere around $80.00.
        Adctitional film is planned, aimed at teaching physicians some of the
        principles required of them in their dealing with patients.  Again, this
        is thought to be less technical and simply reinforcing to physicians of
        their role in the preparation of patients and in the support of patients
        following such procedures.  Again, Dr. Allred and his staff will be
        instrumental in the production of these films.  His estimate is that
        about a half-hour film can be produced for around $900-$1200.  He indicated
        that this was at some variance with the usual commercial cost of $1,000
        per minute but that their expertise and facilities permitted this lower cost.
        The site visitors were not totally aware of the availability of such films
        through other sources.  They were advised that at the moment some material
        is available from medical supply houses and device manufacturers but that
        this is somewhat biased toward the product of that individual concern.
        The team was not aware as to whether or not other Regions are developing
        similar material.
        The site visit team recommended this project as a legitimate request and
        recommended that it be supported in the time and amount requested.




                                              - 17 -                 Rm 00044
           MARYLAND RMP Site Visit
                                                                      1970
           Site Via
                      Regional Oncol    Affiliation-  Dr. Lenhard, Johns Hopkins
           Project #28 -                              al to the site visitors.
                      U@niversity, presented tne propus                     out of
                                                    asibility study, funded
           Apparentl,t this proposal stemmed out of a fe                  Hospital,
                                      oVed an affiliation with the Easton
           Core, in which they have devel
           on the Eastern Shore of Maryland. Ostensibly, this was a program aimed at
           developing affiliations with small hospitals which hoped that this would
           upgrade the knowledge of the local practitioners.  There was, apparently,
           to be feedback to these practitioners upon referral of patients.  There
           was to be heavy emphasis on the establishment of a registry which would
           give them an avenue for feeding back information to the practitioners.
           They hoped to develop practitioners who would have expertise enough to
           recognize cases which should be referred to the Johns Hopkins Oncology.
           Program.  Further elaboration of the program suggested that this was a
           highly service-oriented project, seeking funds for programs which the
           site visitors felt should be an ongoing part of Johns Hopkins programs
           at the present time.  It was difficult to see any structure to the
           educational aspects of the program other than that there would be a
           close relationship to certain individual physicians and, thereby,
           assimilation of knowledge on their part.  Some plans were made for periodic
           rounds, annual seminars, and for having physicians visit Johns Hopkins Hospital.
           A tumor registry was proposed although it seemed that perhaps investigation
           of the role of tumor registries throughout the country had not been
           reviewed by this proposer.  In fact, a tumor registry has apparently
           already been developed in conjunction with the feasibility study.
           it was difficult for the team to understand the justification for the
           salary support that was being requested.  Also, it appeared that there
           might be some confusion as to haw the collection of professional fees
           would relate to this project.
           The site visitors believed this to be an almost purely service-oriented
           program; that it served no demonstration purposes; did not serve as a
           pilot project; or have significant educational values.  The one salvaging
           aspect might be that this program may have real significant regional-
           ization impact.
           The recommendation of the site visitors was that this project should be
           returned for revision.  In making this recommendation, the visitors
           believed that any revision should show the strengthening of the
           affiliation and educational aspects of the project.  it would be helpful
           if some commitment could be obtained, to show that cooperating hospitals
           were committed to the development of some kind of affiliation;and the
           budget should be more realistically planned to defray the costs involved
           in the educational and demonstrational aspects of the program, rather than
           the service aspects of the program.





                                                  18                   RM 00044
         MARYLAND RMP Site Visit
         Pr6ject #29. - A Cancer Detection Program in Children.  This is a proposal
                       to establish physician assistants trained:in the techniques
         for detecting solid tumors by abdominal palpation and Viewing of the reflex
         of the retina in extraocular movements,  It would also incorporate certain
         urine tests and blood tests for the detection of abnormal metabolic products
         which might relate to the presence of neoplasms.  It was proposed that
         three physician assistants be trained in these techniques, to serve in
         weil-baby clinics.  it was anticipated that they would have. to examine
         somewhere around 10,000 youngsters per year, per examiner, in order to   be
         sure that they were detecting significant numbers of neoplasms.
         There appeared to be two aims to the project:  1) to determine   the incidence
         of carcinoma of this type in youngsters; and 2) to demonstrate   the value
         of physician assistants as screening aids.
         The site visitors expressed concern with  reference  to:  1) the assistants'
         ability to really evaluate incidence; 2) the ability to   maintain interest
         on the part of examiners who do such routine work; 3)  .separation of pieces
         into parts rather than incorporating this as a part of a general screening
         program; 4) the lack of concern as to what would be done for followup of
         detected cases; 5) the amount budgeted for D:r. Kyser's salary.
         The site visitors believed that, while cancer detection is undoubtedly
         admirable, this project should be returned for- revision with reference as
         to whether or not it could be incorporated in a larger, more comprehensive
         screening programme
         Project #30    Continui           n_         -  Universi          and School
                        of Dentistry. This proposal  was  not  re iewed during the
         site visit.





                                                   19 -                     Rm  oOO44
       MARYLAND Rmp Site Visit
                                                                       IONAL PROPOSALS
   IWUMMARY OF SrrE
       Project                                          Recommenda
       Nu  er      Tit
                                                        Strengthen Central Core by:
       00           Core                                  1)  Administratively adding
                                                              $150,000  (new  funds).
                                                          2)  Rebudgeting approximately
                                                              $40,000 from institutional
                                                              cores to the Central Core.
                                                          3) Transferring the present part-
                                                               time Medical School Associate
                                                              Coordinators to the Maryland
                                                              R14P Central Core Staff as
                                                              full-time employees (with
                                                              salary  corresponding  to   the
                                                              increased time or effort.)
                                                          St yr-     2nd Yr.       3rd Yr.
         25          Comprehens                          $50,000     $100,000        $100,000
                     Prince Geo            al Hospital             (Direct. osts)
         and
         #26         Stroke            tion Proaram
                     in the                  Prince      rv-els
                     Co        Ith Department
                     Re
                     (Because o  the comp ementary purpose
                     plus the actual physical locations of
                     the applicant  agencies,  the  site  visit
                                  red them as a single proposal.)
                     team conside
                       TOTAL FOR THREE YEARS FOR 4t25 AND 4t26      250 000
         27          mg                                   ist Yr-     2nd Yr.       3rd   Yr.
                                                          $44,975     $44,475       $45,975
                                                                    (Direct Costs)


          28         R      al On,                                Return for Revision
          29         A Cancer Detectio         ram in
                     children                                     Return for Revision







                                                                    pM 00044
     MARYLAND RMP Site Visit                  20
                                              & -FUNDS RECOMMNDED BY SITE VISIT TEAM
                          ESTEE
     SUMMA
     Project                                                  Amounts itecommnded
     Number  Title                 Amounts Requested             (Direct
                                    (Direc                                           Yr.


      25                                            71,390
                                  $209,704  56,911
                TOTAL FOR 3 YEARS - $338,005
      26      Stroke Rebabiili-     $62,751  53,265  55,800
              itati
                         rRels


                 TOTAL FoR 3 YEARS - $171,816

        TOTALS OF PROJ
                                   $272,455 $110,176 $127,190   $50,000 $100,000 $100,000
                 TOTAL FOR 3 YEARS - $509,821
                   (Requested)


                                                                                    45 975
       27                              $44,975 44,475   45,975   $44,975   44,475
               In           omas

                                               LOTALS            $94,975 $144,475 $145,975













                                                                          6/16/70



                         NW















            0                                                              0                                                              0













                                  REGIONAL MEDICAL PROGRAMS SERVICE
                      SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                     (A Privileged Communication)


            MEMPHIS REGIONAL MEDICAL PROGRAM                    RM 00051 7/70.1
            62 South Dunlap                                     June 1970 Review Committee
            Memphis, Tennessee    38103

            Program Coordinator:  James W. Culbertson, M  ID.

            Requested
            Program
            Period                lst  Year         2ad  Year          3rd  Year      TOTAL

            Direct Costs          $360,683           $255,150           $278,358      $894,191
            Indirect Costs           39,368            420598             46,098       128,064


               TOTAL              $400,051           '@297,748          $324,456    $1,022,255


            Note: Project #27 has requested five  years  support:  4th  year  $234,255:
                   5th year $254,816; a total five-year support for the application of:
            $1,383,262 (d.c.o.).  A Review and Funding History is attached to the back
            of this summary; henceforth referred to as (R & F.H.).

               tor : The grantee institution for the Region is the University of
                      Tennessee.  The Mid-South Medical. Center Council (MMCC) for
            Comprehensive Health Planning servos as ttie RMP Regional Advisory Group.
            The original planning grant period for this Region  was  approved  for  two
            years and three months, April 1, 1967 - June 30, 1969.  The first-year
            award was for $136,056 (d.c.o.). A total  of  $294,737  (d.c.o.)  was  made
            available during the second year.  An award of $118,043 (d.c.o.) was made
            for the third-year planning period of  three  months.  In  order  to  merge
            planning activities with the operational  grant,  the  third-yoar  planning
            grant period was extended three months, July I - September 30, 1969, and
            a supplemental $89,022 (d.c.o.) was provided, making a total of $207,065
            (d.c.o.) available for the third-year (six months) of planning.

            During its second year of planning, t@i@- Region implemented  a  three-year
            operational program with an award of @592,063 (d.c.o.) for the support of
            ten projects for the first year, July 1, 1.968 - June 30, 1969.  In November
            1968, Council considered the Region's first supplemental operational appli-
            cation which contained three proposals in the areas of medical technology
            training, provision of diagnostic facilities and multiphasic screening.  The
            total application was disapproved with advice that it be revised and resub-
            mitted.  The application did not clearly relate to the developing regional





         MEMPHIS RMP                    -2-                 RM 00051 7/70.1


         strategy.  In February 19694 Council considered a second operational
         supplement which contained three new projects in the areas of  coronary
         care training, education in medical technology, and medical  laboratory
         service. The coronary care training program wag approved and  funded  at
         $54,380 (d.c.o.) for th'a first-year.  The remaining two projects were
         deferred for an April 1969 site visit and in May, Council recommended  dis-
         approval of the medical technology project with advice that it be  revised
         and resubmitted. since the proposal had failed to establish its  importance
         in meeting regional.needs. The laboratory service project  was  disapproved
         and not considered appropriate for RMP support.
         Support for the coronary care training program and for the second year  of
         operation for the ten projects fundedlunder the initial operational  grant
         was provided through an award of $679,046 (d.c.o.) for the period of July  1,
         1969 - August 31, 1970. However, use of funds for the  peripheral  vascular
         disease project and the Obion County General Hospital project was either
         partially or totally restricted pending the submission of additional
         imformation. It appeared that the vascular disease project, which  had  been
         approved for planning activities only, had actually become  operational.  The
         Obion Hospital project, which was funded to increase hospital capability
         for the categorical diseases, had made no progress and future  plans  were
         unclear. The financial restriction on the Obion Hospital project is  still
         in effect.
         In May 1969:* Council considered a third operational supplemental application
         which requested renewed and expanded support of core staff and eight new
         projects, two of which were multiphasic screening proposals.  The  remaining
         concerned cardiovascular clinics, renal failure training center, care of high
         risk infants, nuclear medicine technician training, bi6od banking,  and
         surveillance of hospital acquired infections. The application  was  site
         visited in July 1969, and considered again by the Council in  August.  Core
         staff support, the two multiphasic programs and the cardiovascular  clinic
         program were recommended for funding. The hospital acquired  infection  pro-
         gram was approved, but without funds. The renal failure training  and  the
         nuclear medicine training projects were disapproved and  considered  inappro-
         priate for RMP support. The high risk infant and the blood  banking  projects
         were disapproved with advice that they be revised and resubmitted.
         The site visit team helped clarify the Regiods spate of program  development.
         At that time, the overall goals and objectives were not clearly  delineated.
         An attempt was being made, hoiyever, to create or even recreate an environ-
         ment wherein programs could be mounted, priorities assessed, and goals  and
         objectives at least visualized if not established.  Planning  activities
         were not impressive up to that time.  For example, there had been no
         formal recommendation for regionalization of the areas outside Shelby  County
         area, ' ftere was a lack of involvement of many rural areas. There  was
         evidence, however, that involvement of rural areas was slowly being increased.
         Further, the team noted complications arising from the RMP and MMCC relation-
         ship. It was recommended that the RMP give top priority to overcoming  the
         resultant problems. Also, it was believed that the RAG might  function  more
         effectively if it contained a larger representation from outside  Shelby
         County.



           MEMPHIS RMP                             -3-                   RM 00051 7/70.1

           In December  1969, Council  reviewed  the  Regii)es,  Fourth  Supplemental  Operational
           Application  which  requested  support  for  Projects  #25  -  Demonstration  Program
           in  Health  Care,  and  #26  -  Biomedical  Information  Network.  Council   approved
           with  conditions  the  Home  Health  Care  project  and  disapproved  the  Biomedical
           Information Network project. (Refer to R & F.H.)        The   total   amount   recom-
           mended,, but unfunded at  this  time,  for  the  total  application  was  $1,211,405.
           Two of  the  R.egion's  approved  but  unfunded  projects  #17-  Demonstration  Program
           in  Preventive  Service,  and  #18-Mobile  Multiphasic  Health  Screening,   are   to
           be partially funded in  FY  1970  from  the  recently  released  $5  million  of  the
           $20 million carried forward from FY  1969.  Also, currently under administrative
           consideration is the  Region's  request  to  use  $155,172  of  the  $227,000  01  year
           unexpended  funds  to:  help  support  projects  #17,($29,470)   and   #18,($52,633);
           initiate  three  approved  but  unfunded  projects,  #19  -  Cardiovascular  Clinics,
           ($25,752),  IP24  -  Surveillance  System  -  Hospital  Acquired  Infections,($5,092)
           and  #25  -  Demonstration  Program  in  Health  Care,($10,493);  and  to   purchase-
           cinematic  photograph  equipmen@  and  additional  office  furniture  and   equipment
           for 1--hi. core staff facilities, ($31,732),
           p            ication:  The supplemental grant application is requesting
                                   $1,022,255 (d.c.o.) for three-years support of two
           projects,  Both  projects  in  this  application  are  resubmittals,  project  #4   -
           Peripheral Vascular Clinic.  and  project  #23  -  Regional  Blook  Bank  and  Trans-
           fusion  Program.  The  Peripheral  Vasculai@-  project  was  granted  by  Council  in
           May  1968,  a  planning  award  for  developmental  activities  and  regional   plan-
           ning.  After  one  year  of  operation,staff  reviewed  the   continuation   applica-
           tion of this project and found that the project has assumed  operational
           status  for  which  approval  had  not  been  granted.  A  restriction  was   imposed
           on 50% of the approved amount pending receipt of additional information
           regarding  this  proposal.  After  quite  an  extensive  amount  of  negotiation   with
           the region and a special action by Council in December 1969, the region
           was given approval to utilize their remaining funds to phase out their
           planning grant  and  recommended  that  they  submit  a  revised  proposal  for  full
           operational  project  support.  The  Region  was  advised  that  the   new   proposal
           should  not  only  clearly  describe  those  activities  which  are   considered   as
           provision of patient  services  and  those  which  are  considered  as  training  and
           educational  components,  but  that:  a  detailed  budget  justification  be  presented
           accordingly,
           The B','@66d Banking and Transfusion PrograrT,@, i,7as reviewed by Council in  August
           1969,  nd disapproved.  Council. believed that the relationship of this proposal
           with existing blood banks, hospitals or medical care programs needed strength-
           enirig and that  the  project  needed  to  be  coordinated  with  the  local  Memphis
           Blood  Club,  The  financial  arrangements,  especially  those  related   to   income
           to bederivedfrom sale of blood derivatives s needed classification.         Council
           also believed that the  proposed  program  it@@@eded  more  involvement  of  physicians
           and technologist in the Region.      FtirtliE@@', @he proposal raised major  implica-
           tions of  a  unified  transfusion  service  for  all  hospitals  within  the  Tennessee
           Medical Center Complex.
               ect #27 - Per                              The Region states that       Requested
                          dur                            el.opmental stage, the        First Year
                                                                                       $47,761




         MEMPHIS RMI'                          -4-                  RM  00051  7/70.1


         first six months were devoted'towards procurement of clinic space equip-
         ment and personnel.  The stcond six-months were devoted to developing a
         facility and to test various organizational concepts, function, methods
         of patient  care  delivery,  impiove  efficiency  and  evaluate  the  feasibility
         of later self-support or community financing.
         This @rogram proposes to implement the following Activities:

            A.  Education
                    (1) Public  Education  -  Develop  and  distribute  pamphlets  through-
                        out the community which d6scribes the warning signals of
                        vascular  disease,  the  cause  and  possible  complications,
                        utilize the public information medias to urge medical and
                        paramedical  personnel  to  help  disseminate  knowledge   to
                        patients' friends and families.
                    (2) Physician Education - By developing and     'distributing  a   Univer-
                        sity  Clinic  brochure  describing  the  facilities  and  services
                        available at the clinic,  by  the  staff  of  the  university
                        clinic preparing  and  presenting  a  lecture  series  on  vascular
                        disease,  and  through  consultative  services  by  the  University
                        Vascular Clinic Staff:to private practitioners.
            B.  Increasing Quality and Quantity of the Skilled Profession,,il and
                Paramedical Personnel in the Region
                    (1) Nursing  -  Establishing  nursing  in  service  training  programs
                        for RNs and LPNs in hospitals and having seminars for
                        public  health  nurses  and  Visiting  Nu@ses  Association  Staff,
                        by the  University  Vascular  Clinic  giving  a  nursing  education
                        workshop for nurses in the region who will staff regional clinics.
                    (2) Paramedical Personnel  -  The  vascular  clinic  staff  will  partic-
                        ipate in  the  University  School  of  Physical  Therapy,  delivering
                        that portion  of  the  instruction  which  applies  to  peripheral
                        vascular disease.  They will also sponsor an educational
                        activity  for  paramedical  personnel  employed  by  the  Division
                        of Vocational Rehabilitation.

            C.  Improving Patient Care
                    (1) University  Vascular  Clinic  -  The  organization  function,  and
                        staffing of this  clinic  has  proceeded  from  the  basic  concept
                        that total service  should  be  provided  in  one  centralized  area.
                        This  involves  physicians'  services  for  diagnosis  and  treat-
                        ment, nursing  care,  adequate  social  and  economic  ddta,  on-the-
                        spot  consultation with the vocational rehabilitation counselor,
                        a physiotherapist to advise both physicians and patients, and
                        complete diagnostic instrumentation.  Referrals will be received
                        by letter or  phone  from  physicians  or  any  appropriate  social
                        agencies (DVR, VNA, etc.).  Referral to the clinic will receive
                        a clinical evaluation by one or more members of the staff.
                        There will be available at the clinic out-patient angiography
                        which will allow  a  more  definitive  immediate  diagnosis  and  a
                        complete workup.  All patients will be scheduled for a follow-up
                        evaluation either post-treatment or after being returned to the
                        referring physician for management.




                                           -5-                  RM 00051  7/70.1
        MEMPHIS RMP
                   (2) Regional Clinics - Regional Clinics will be instituted in
                                                                         u
                       the Memphis Region to expand the educational and  service
                       function of this program. Physicians from  Tennessee  and
                       one from Mississippi, have indicated interest in  putting
                       up a regional clinic. The interested physicians  will  be
                       invited to Memphis to observe the functions of the clinic
                       and have a planning session to determine their needs and the
                       facilities available in their area.  The physicians will .
                       then select personnel from their area to attend the Univer-
                       sity Vascular Clinic weekly for four weeks for on-the-job
                       training.  This should include the secretary, the nurse, and
                       the x-ray technician. At the conclusion of  the  training
                       period the University Peripheral Vascular Clinic itaff wou4d
                       make a site visit to assist in setting up the regional clinic.
                       The regional clinics would then begin operation with one or
                       two members of the University Peripheral Vascular  Clinic
                       attending for three or four months and then they will function
                       as an automomous unit.  The basic concept is that the more
                       routine cases would be handled locally and only the  most
                       difficult cases would be referred to the University Peripheral
                       Vascular Clinic for consultation.


             D.  Vascular Registry
                   (1) A peripheral vascular disease registry will be established
                       utilizing a keysort system with information stored on punch
                       cards.  Present Clinic population will be incorporated into
                       the registry first and new patients will be added as they
                       come to the clinic.  Later as regional clinics become estab-
                       lished patients who attend these clinics will be added to the
                       master registry.  The information to be stored on the cards
                       will be obtained from the clinic charts and supplemented by
                       patient interviews whenever necessary.

             E.  Clinical Research
                   (1) A close observation will be maintained for clinical research
                       of those patients with Ileofemoral  Thrombophlebitis  and
                       Saphenous Vein Al.lografts.
         For evaluation of the program art annual statistical report of clinic activ-
         @ ies in the area of patient care will be compiled and reviewed.  In addition,
         it
         a questionnaire will be prepared and mailed to referring physicians request-
         ing his opinion of clinic activities.  A subjective evaluation of educational
         activities in the clinics and community       be directed to those people
         who have been in contact with the clinic.
         The major portion of funds requested are ti@@ider the category of personnel.
         The applicant states that the procurement of a vascular fellow is vital to
         the basic function of this clinic-education.  The initial six-month scholor-
         ship stipend is for a potential candidate already contacted and interested
         in the position.  After this, the region anticipates that fellows will be
         appointed by the University for. one year.
         Second Year:     $57,056                  Third Year:  $62,991




                                            -6-                 RM 00051  7/70.1
        MEMPHIS RMP


        Project #28 - Regional Illiod Banking and Transfusion Program.            Reques ted
                       Submitted by the Baptist Memorial Hospital and the         First-Year
        College of Medicine, University  of  Tennessee,  this  proposal  presents $312,922
        a plan  to  provide for the Region teaching and consultative services
        which are  not  now available. It is proposed  that  the  local  blood  bank-
        ing  center  become an extension of existing  facilities  at  the  Baptist
        Memorial   Hosptial and be housed away from the Baptist Hospital.
        The  objectives  of this project are: 1) to  provide  means  of  rapidly  indenti-
        fying  blood   bank problems and determining if the  problem  can  be  cared
        for at the local facility, or hospital,  or  temporarily  referred  to  the
        main center; 2) make available for patients  blood  and  its  components  to
        improve patient care and educate those in the Region  on  the  use  of  specific
        components; 3) make available facilities  for  Regional  courses  and  workshops
        for continuing education in blood bank  immunology;  4)  make  available  facili-
        ties for advanced training of technologist in  all  phases  of  blood  banking;
        5) make available facilities for training  of  medical  and  technical  directors
        of blood bank facilities; 6) maintain an inventory  of  rare  donors  and  rare
        blood; 7) stay abreast of the developments in  this  field  to  implement  worth-
        while advancements for educational and improved  patient  care;  8)  through  a
        fellowship program, evaluate proposals  which  are  in  clinical  investigative
        phases; and 9) maintain facilities  for  thorough  investigations  of  problems
        in blood banking, including the  recipient  who  has  frequent  transfusion
        reactions.
        The proposal is especially arranged so  that  its  implementation  would  not
        pre-empt any of the blood  supplying  facilities  and  transfusion  services of
        the Region. Rather, it is geared to  strengthen  these  through  a  major  year-
        round educational program. The  Memphis  blood  bank  directors  support  the
        program so long as it does not  interfere  with  their  routine  service  func-
        tions as presently instituted.    Thus, it does not  Appear  possible  to
        establish at  present  "a  unified transfusion service for  all  hospitals  with-
        in the  Tennessee  Medical  Center Complex." The  blood  bank  directors  of
        Memphis  and  Jackson,  Tennessee, have pledged support for  the  program  as
        presented and will  serve  on  the advisor committee.  The  Region  believes  this
        could be a nucleus for a future community  blood  bank  operating  as  an  entity
        outside of  any  single  hospital.
        The service part of the proposed plan  would  entail  only  what  established
        organizations cannot supply. Included  would  be  rare  donor  blood  from  the
        frozen blood section and components  for  the  treatment  of  hemorrhagic
        diseases, such as platelet concentrate, and cryoprecipitates and fresh frozen
        plasma. It will also include the  availability  of  a  'hot  line"  for  insti-
        tutions in outlying areas. This would be  utilized  in  case  of  any  problems,
        such as a cross-match problem, the  situation  can  be  considered  immediately
        over this 'hot line". A tissutt typing  service  will  be  offered  to  outlying
        institutions, especially as the  renal  dialysis  programs  expand  to  include
        both center dialytis to home dialysis.
        The program's main activity will  be  in-disseminating  information  on  modern
        blood transfusion practices. As such,  a  major  educational  program  for  the
        region would be established  emphasizing  workshops,  lectures,  visits,  and





         MEMPHIS RMP                      -7-                 AM 00051 7/70.1


         consultations.  From these approaches the Region envisions greater interest
         in improving blood transfusion facilities and modernizing medical practice.
         Of the first years budget:  22% is requested for personnel - 2 full time
         Instructors, 5 full-time technicians/technologists, 2 full-time clerk-
         typists, and 2 full-time custodial employees; 32.64 is for supplies; 20.3%
         for equipment; 23% for renovation; and 2% for travel and other items.
         Second Year:  $198,094                     Third Year: $215,367
         Fourth Year:  $234,225                     Fifth Year: $254,816





                                                                                        RM 00051 7/70.1
           MEMPHIS RMP



                                     REVIIli   AND FUNDI@NG   II]-.STORY,

           Ist Year  Pliriiiing  ki@iircl       4/l/67-3/31/68                             $173)119
           (February    1967     Council)

           2iicl Year  Pliiiiiiiig  Award       6' /I/68-3/31./69
                                                                                            .183)443

           3rd Year Planning       liward       4/l/69-9/30/69                               249,490

           INITIAL OP),"IZATIONAL  APPLICA@']-'ON  CO'@IPON),-NTS
           (Site visited June 1.968)
           Olay 1968 Council)

                                                                     Appr2v@cl
           Projects                                             Project       Period       Funded (d.c.o.)

           #1 - Stroke Center in the       Memphis Region            3   years     (01)$     86,606
                                                                                  .(02)    .148,522
           i4l2 -Regional Laboratory for Gastrointesti-
               nal Mucosal Suction Biopsy                            3   years     (01)    18,000
                                                                                   (02)    -23,325
           #3     evention and Improved Treatment of
               p
               Skin Cancer                                             years       (01)    29,590
                                                                                   (02)    34,998
           #4 -Peripheral Vascular Disease                           3 years       (01)    20,000
                                                                                   (02)    23,93-0-
           #5 -Coronary Care Training Unit                           3 years       (01)  130,000
                                                                                   (02)  106,2  -68
           #6 -Emphysema and Cor Pulmonale                           3 years       (01)    59,928
                                                                                   (02)    69,144
           #7 -Streptococcal Disease Center                          3 years       (01)  103,252
                                                                                   (02)  101,310
           ii8-Electrocardiographic Diagnostic Center                3 years       (01)  108,687
                                                                                   (02)    70,,499
           #9 -Obion County General Ilospitrl Project                3 years       (01)    21,000
                                                                                   (02)    23,322    I/
           Y@10 -Combined Attack on Certain Forms of
               Heart Disease, Cancer and Stroke                      3 years       (01)    20,000
                                                                                   (02)    23,332

              (Total restrictions on use         of funds)

           FIRST OPFRATIONAL SUPPLFA14L;'LNI'AL       APPLLCATION
           (November    1968     Council)



                                                                Proiect       Period       Funded

           #11 - Regional Medical Technology School                                Disapproved with A(Ivic(@
                                                                                   to Revise and Resubmit
           #12 - Radiological Diagnostic Fqu5plnc,.Ilt                             Disapproved with Advice
                 at Crittenden Iloc.,,pj.t@il.                                     to Revise niid Rc!sul)mit
           #13 - Denioiistratioii Program in Preventive                            Disapproved with Advice



           MEMPHIS RMP                             -9-                           RM 00051 7/70.1

           SECOND SUPPLEMENTAL OPERATIONAL APPL'LCATION COMPONENTS                       Funded
           (Fe             Council approved@      4@,   and   fl5
           and  #lCo  %qere  deferred  for  an  April  1969  site
           visit.  Final action taken by May 1969 Council)
           #14 - A Propot@@.,  @.  for  a  Cardiovascular  Inten-   3 years   (01) $54,380
                  sive  Care   Unit
           #15 - Education in Medical Technology                               Disapproved    with    Adttce
                                                                               to Revise and Resubmit
           #16 - Improved Quality Control and Service                          Disapproved
                  Of MP-dical Laboratories
           THI@'  "" . F          PEZ  T'ONAL APPLICATION       0  ONENNTTSS
                      Con         f
           (May 1969        @i'lLdoe   ed    total    application
           for July 1969 site visit.   Final action taken
           by August 1969 Council)
                                                                   Approved
                                                                Prolect Period               Funded
            @1)   Cc're Staff                                      2 years          (01)    $504,000
           #17  - Proposal for a Demonstration Program             3 years          (01)        240,000(new)
                  in Preventive Services for Heart                                                 29,470(carry-
                  Disease, Cancer, Stroke and Related                                                  6ver)
                  Diseases
           #18  - Mobile Multiphasic Health Screening              3 years          (01).       260,000(new)
                  Unit in Northeast Mississippi                                                    52,633(4arry-
           #19  - Expansion of Cardiovascular Clinics                                                      over)
                  in Northern Mississippi                           3 years         (pi)           25,752(carry-
           #20  - Development of a Chronic Renal                                                           over)
                  Failure Training Center                                           Disapproved
           021  - Care of High Risk Infants                                         Disapproved with Advice
                                                                                    to   Revise   and   Resubmit
           #22  - Improved Patient Care - Regional                                  Disapproved
                  Nuclear Medicine Center
           #23  - Regional   Blood   Banking   and    Transfusion                   Disapproved with Advice
                  Peogram                                                           to   Revise   and   Resubmit
           #24  - Feasibility   Study    -    Establishment,,6f@a   2 years         (01)           5,09'-(carry-
                  Central Regional Surveillance System                                                     over)
                  f@)r Control of Hospital Acquired
                  Infections
           p             EMEN'IAL OPERATIONAL APPLICATION COMPONENTS
           I                      cil)


           @o ects
           ii25 - Demonstration Program in
                  Health Care                                       3 years         (01)      $20,600
                                                                                                   10,493(carry-
                                                                                                           over)
           #26 - Biomedical Information Network                                     Disapproved with
           0                                                                        advice  to  revise   and
                                                                                    resubmit


                                                                                    RMPS/GRB/6/3/70





                                                                                   (A Pi-ivil-c!ged Cc)iiir@luni.cation)




                                          S@IT,IARY OF REVIEtl Al\'D CONkoLUSI.Ol@ OF
                                              JUNE 1970 IU,"VIE@l


                                         MEI,IJ.1111S REGIO@,@A-il MEDICAL PROGRAM
                                                    RM 00051 7/70.1


                                  FOP, COiiSIDEIIATION BY JULY 1970 ADVISORY COUNCIL



                 General:  The Co@iimittee concluded that this application which requested
                              $894,191    (d.c.o.)    for    three    years    support    for     two     proposals
                 slioul-d not be approved.  Both project proposals represented resubmissions,
                 al,though of a different nature.   Project #27,  for a Peripheral Vascular
                 Cl.i.n:ic   has    evolved    into    an    ongoing    operational    activity    during    the
                 first   two   years   and   funds   were    beiiic,    requested    to    extend    the    program
                 for over a thre(---.year period,   Project #38 for @t Regional Blood
                 Banki-iic-,   and   Transfusion   Prograrii   was   a   revised   proposal   and    hi,@;    never
                 been initiated.


                 Project #27 - Per@i-plicral Vascul-ar Clinic

                               This proposal was incl.uded in the original application.
                               for operational funds; it was not approved as ar, operational
                 project,    but    funds    were    awarded    for    further    planning.     D,,Iring     review
                 of a continuation app-l.i.cat-ioi-i, staff noted that the activity had
                 advanced beyond planning to operational status.   Special action
                 by    Council    clarified    the    re(-,ion's    authority    for    the    ongoing    clinic
                 development and permitted tire for the Region to E@ul),-iiit an application
                 for continued support of the clinic.

                 The Coiiiiyij-ttee had real concerns about this activity, not for its inherent
                 v,4.1.tic- but for its app,,-opri,at-.E@lies@s as an I-Cifll funded project.           A rec'errlil-
                 service is beii@@, developed,  ind clinical- fellow                              is      being
                 supporters       Two coiii7,itiL-iity c-l-i-i-,-ics are be-i-i-ic, envisioned for small
                 peripheral   coi,,imLini.tier,,   but   the   Coinmi.tt(-,e   questioned   tl).ei2-   essenti,,'I-
                 value.      The referral. center i-ri Mc@uiph.!,f-@                   serves     a     function
                 a registry and research activities are also
                 education through referral of patients is Val-Lllb"-c.                      The Coiii,@ii.ttec!
                 di.d riot question the -val.ue ol- the referral                          but i.t did
                 question the validity of                    suppoi.,[@i.j,@r, it.  The
                 aspects - public,  physician and allied Health education,
                 peripheral  clinics -irc,. not                                           of this project:.
                 The  Coiiifi-titte(-,   concluded   thEit.   this   activity   should   I)c,   not   ip[)rovcd
                 for Pi,,Rl fi-ind:liic,.  Tlii.s rc,.coiiii)@c@ndatioii does not i,cf--Lcct on the essential
                 value of the referral.. center activity.

                                    the Coi-@tir@ittco i,c,copi-ii,zed that the               iuly   need    to
                 I)ha,,@@ out: three in -An orderly Ti)@ii.-iii(,r ii@cl                                      ]lot


                                                           I,




               Meinphis Regional
               14edical Program                        2 -                        Pll 00051 7/70.1


               Project 1128                                           s
                                 _k n@aL Bl-c)ocl Bani@:Lii.@,,, and ']'rai:isfi-t ion Pro7raiTi
                           The Coiiini-i-ttee recognized  that  this  proposal  was  an  adapt
                           ation of one which had been previously returned for revision.
               The previous review had raised questions concerning the relationship of
               the activity with existing blood bank, hospital and ricdical- care
               programs, as well- as  to  the  Meirpliis  Blood  Banking  Club.  Financial
               arrangements needed clarification.       The involvement of physicians ,
               technologists as well as the unification of transfusion services for
               all- hospitals within  the  Tennessee  @ledical  Center  Coiiiple)c  were  also
               points of concern.
               The Committee was concerned that this revised proposal did no,,- indicate
               clarification of the important relationships which the previous
               review    requested.  Regionalj.zati.oi-i is proposed, but it involves only
               one hospital in the Memphis lledical Center'Conipl-e>z and peripheral
               hospitals.  In  fact,  it  was  noted  that   cooperative   arrangements   with
               other hospitals in Mciiiphis were not feasible at this time.
               The Cc)rirAittee felt thaL this type of cooperative arrangement - outside
               of Menipliis, but without other niajor @icinpl-iis hospital component-.,,; - r,,,,otild
               jeopardize and  hinder  needed  regioiialj-za.tion  in  thisi.mportai.it  area.
               Other  aspects  noted  in  review  were  the  absence  of  objectives  for  the
               technologists' training, the lack of  justification for the equipment
               and the question of fellowship training.
               Reco3Timen-dat-i,on:-  Non-Approval I, No R@ff)S funding recommended


                              l@VIET,@l CO',.,EITTTI.,-E FATDI.NG 11,ECOI,@,)-,,NDI\TTOI@S

               Project
                                     Year       @@q@i c@ -@, t e cl 01 Year  02 Year  03 Year Total-
                  27                  01           $47,761
                                      02              57,056                  --O-
                                      03          _@2,_g 9_L
               SUB TOTAL                            $167,808

                  28                  01           $31-2,922
                                      02           1,98,09/@
                                      03           215,367          -0-       -0-      -O-.-     --O--
                                      04           234,225
                                      05           254,816
               SUB TOTAL                         $1,21.5,424
               TOTAL                             $1@,383,232         0        -.0-      -O--     -.O--

















            0                                                             0                                                              0





                               REGIONAL MEDICAL PROGRAMS SERVICE
                 SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                  (A Privileged Communication)

         METROPOLITAN WASHINGTON D.C.                         RM  00031   7/70.1
          Regi.onal Medical Program                           June 1970 Review Committee
         2007 Eye Street, N.W.
         Washington,  D.  C.  20006

         PROGRAM COORDINATOR:  Arthur  M.  Wentz,  M.D.

         Requested:               Ist  Year           2nd  Year        3rd  Year      TOTAL
         Direct Costs             $114,731            $106,515          $ll3j495      $334,741
         Indirect Costs              40,148              43,134           46,098      129,380


         TOTAL                    $154,879            $149,649          $159,593      $464,121
         HistorV: The Regi.on's first year of  planning  was  a 14-month  period,  I/l/67-
                   2/28/68, and was supported at  $188,000.  Following  a  site  visit  in
         Februar)@ 1968 the Region was awarded $241,642 for  planning  and  $350,506  for
         support of three operational projects,  both  for  the  period  3/l/68-2/28/69.
         During the 02 year of operational status, 3/l/69-2/28/70, the Region was
         awarded $1,400,416, of this, $554,908  supported  Core  and  $845,508  supported
         nine operational projects. As a result of  the  February  1969  Review  of  the
         Region's continuation application, it was awarded $980,514 for the 03
         operational year 3/l/70-2/28/71; Core is  supported  at  $554,034  and  twelve
         projects at $426,480. During the first  two  years  of  operational  status  the
         Region has submitted approximately 35  projects  for  DRMP  review.  The  Region
         currently has four approved  but  unfunded  projects.  The  projects  currently
         being supported are outlined on an attachment to  this  summary,  as  are  those
         projects which for one reason or another have not been funded.

         In its review of the continuation application for the third operational year,
         RMP staff noted that some progress had been made  in  core  staff  planning  and
         coordination, that the RAG has  been  reorganized  with  broader  representation
         and that a Priority Committee of the  RAG  composed  of  representatives  from
         the categorical review committee was  actively  engaged  in  overall  priority
         determinations. Furthermore, this  Region  has  actively  sought  involvement  of
         the suburban Virginia and  Maryland  communities.  However,  involvement  of  the
         community representative of the City of Washington was not apparent; in fact,
         involvement of Blacks and consumer  groups  generally  is  minimal,  particularly
         at the decision-making level. Furthermore, there  seemed  to  be  a  dearth  of
         core staff time and interest committed  to  cooperative  planning  for  better
         health care of the inner-city residents.  The Region has been asked to
         respond to these concerns of staff before July 1, 1970.

         Present Application
                                                                                     Requested
         Project i@36 - Diabetes and Obesity Evaluation and Prevention Program.  First Year
                       The long-range goal is the establishment of methodology       $71,754
   ,,and standards  for  the  early  identification  of  those  children  likely
         to develop diabetes mellitus with its attending degenerative compli-
         cations and the institution of prophylactic measures to prevent further




        METROPOLITAN WASHINGTON D.C.                -2-             RM 00031  7/70.1
         Regional Medical Program
        progression of the disease complex.   Th e process for achieving this
        is based on the hypothesis, suggested by preliminary  results  of  prior
        testing, that adult symptomatic diabetes is preceded  by  asymptomatic
        biochemical abnormalities in childhood which can be detected and
        identified; and that children of diabetic parents, siblings of
        diabetic children, and obese children and their siblings represent
        a predisposed group.
        A Pediatric Regional Community Diabetes Evaluation and Prevention
        Center established at Georgetown University Medical Center  is  proposed
        to provide a service for early diabetes detection in the pediatric age group
        and hopefully, for prevention.   The Center would encourage referral
        from private practitioners, health departments and school  agencies,  of
        children in the predisposed group.   Secondary screening centers will be
        established in five collaborating hospitals:  Arlington Community,
        Fairfax, Children's, Providence, and the Hospital for  Sick  Children.
        Blood samples of children examined at the secondary centers will be
        referred to the primary center.  Although it is estimated 50-100 siblings
        of diabetic children will be examined, no estimate is made for the number of
        children of diabetic parents, or obese children and their  siblings,  to
        be screened.  Other goals are to: establish  comprehensive  diagnostic
        guidelines for,the recognition of the prediabetic stage in the pediatric
        age group, and to establish monthly conferences and progress reviews as
        a form of continuing education in the private physicians and other
        interested groups.   Evaluation as outlined is limited to  blood  testing
        procedures and analyses.
        The personnel budget request is based on  experience  gained  during  the
        past two years of preliminary research cond Iucted on obese children  and
        siblings of diabetic children, which was supported by a  grant  from  the
        National Institute of Arthritis and Metabolic Diseases.    The  applicant
        states the proposed application of this experience  cannot  be  continued
        without financial support.   The budget request for personnel is $50,854.
        The major item in the equipment category  is  Gamma  Counting  Equipment,
        $12,000.
        Second Year:  $61,397                        Third  Year: $64,067
                                                                                Requested
        Project #37                         hronic Obstructive  P   nar         First Year
                       Disease (C       This  project,  presented by the         $42,977
        Pulmonary Division of the Howard  University  College  of Medicine   and
        Freedmen's Hospital, is directed at improving the effectiveness of
        unaffiliated practicing physicians  in  detecting  and  treating  Chronic
        Obstructive Pulmonary Disease.  A short course in the clinical,
        pathophysiologic and therapeutic features of COPD  will  be  taught  to
        60 physicians and their assistants over  a  three-year  period  through
        lectures, demonstrations and the inquiry method.
        Four courses presented each year will  accommodate  five  physicians  and
        their office assistants.   The curriculum is  designed  to  be  presented
        in two sessions for a total of six hours instruction.    Attending





       METROPOLITAN WASHINGTON D.C.            -3-             RM 00031  7/70.1
         Regional Medical Program

        hysicians and assistants, where appropriate, will be  offered
       additional courses in pulmonary diseases at, and supported  by
       Iloward University.  Upon completion of the course each partici-
       pating physician will be provided'with a "relatively  inexpensive"
       ($225) vitalor, and respiratory history forms so that  he  may
       undertake private office screening of all patients over the age
       of 40 an(] all patients with histories or physical findings
       suggestive of COPD.

       Patients presenting positive findings will be directed to  the
       function laboratory at Freedmen's Hospital for more detailed study.
       Initially ten patients weekly will be fully tested. This  will  be
       raised to 15-20,by the end of the first year. Those  confirmed  to
       have COPD will 'De referred back to the private physician for treat-
       ment and follow-up.  Although the applicant states the project will
       compliment the Georgetown University Adult Breathing Improvement
       Course and the Inhalation Therapy School at Washington Hospital
       Center, already approved by the Metro-Washington RAG, no  specific
       plans for coordination are included.  No specifics are provided as
       co how the Breathing Equipment Loan Service will serve as an assisting
       agency.

       A general plan for evaluation is presented.

        econd Year:  $45,118                             Third Year:  $49,428




       METROPOLITAN WASHINUI'UN 1).U.
         Regional Medical Prograrn
       Summary of projects currently being supported by MRtro. D.C. RMP
       Pro  ect Title and Number                 Approved Project           Funded 3rd Year
                                                        Period             (direct costs)
                                                                            3/l/70-2/28/71

       #1    Freedmen's Hospital Stroke Station           3 Years              $   16,100
       li2   Cardiovascular Disease Follow-up             3 Years                 97,812
             and Surveillance - GeorgetowA
       #3    Training for Cardiovascular Technicians      3 Years                 19,600

                                                                               Funded 2nd Year
                                                                                         costs)
                                                                                  (direct
                                                                               3/l/70-2/28/71

             Core                                         3 Years                 554,034

       #5   -Audiovisual Library of Ovarian Neoplasms     3 Years                   2,500
             for Continuing Education
      #10   -Comprehensive Care of Patients with          3 Years                   7,500
             Pultionary Disease - Georgetown
      #12   -Mobile Coronary Care Unit                    2 Years                 50,000
      #19   -Metropolitan Washington Regional             3 Years                 40,000
             Cancer Registry
      #20   -Metro Washington ileripheralvascular         3 Years                 50,000


                                                                               Funded Ist Year
                                                                                 (direct costs)
                                                                               3/l/70-2 /28 /71

      #23 - School of Inhalati       era                  3 Years                 12,600
      l@26  -Comprehensive Community Hospital             3 Years                 49,438
             Stroke Program - Arlington
      #28   -Coronary Care Nurse Training                 3 Years                 14,790
             Freedmen's School of Nursing
      #29   -Mass Screening, Tre       and                I  Year                 16,206
             Eradicating As)rmptomatic Bacteriuria
                                                             TOTAL               $980,514






                      @IETROPOLTTAN WASHINGTON D.C.                                     -5-                          @l        00031  7/70.1
                      Regional @ledical Program


                      Status  of Projects not  funded

                      Project Title and Number                                                                                        Status


                      #4 -      Home      Telecasts      of      Medical-Surgical      Conferences                                 Disapproved

                      #6-Comprehensive     Hospital     and     Home      Care      of      Stroke Patients                        Disapproved

                      .7-Puerperal Hemiplegia                                                                                      Disapproved

                      '@8-@iodel  Stroke  for @letro.  D.C.                                                                        Disapproved

                      "@9-Coronary     Artery     Disease:      The      Role      of      Exercise                                Disapproved
                      in  its Management

            '@ll      -@lobile Coronary Care Unit  for @letro.  D.C.                                                               Disapproved
            #13       -i@lobile Coronary Care Unit  - Georgetown University                                                        Disapproved

                      16-Paramedical Retraining by Video Tapes                                                                     Approved
                                                                                                                         (No  funds  recommended)

            "'17      -Health Careers  Council                                                                                     Approved
                                                                                                                         (No funds  recommended)

                      18-Application of Technological Advances  to                                                                 Disapproved
                      Education  in Cancer

            '@@21     -A@ lying Community  Health Research Findings  in  the Region                                                Disapproved

                                                                                                                                   Approved
            ,@22      -Pediatric  Community Kidney Disease Prevention Center
                                                                                                                         (No funds recommended)

            "24
                      -Attempt     to     Imp)rove     Care     and     Patient      Cooperation                                   Returned       for
                      in Hypertension                                                                                                Revision

                      -Cancer Radiotherapy Unit  - Education Consultation Service                                                  Approved      but      Unfunde(

            @"27      -Continuing Education and  Social Services  for Pediatric Oncology                                           Disapproved

            #28       -Coronary Care Training  - Freedmen's,                                                                       Approved      but      Unfundec

            #30       -Community Renal Diagnosis  Service Using Immunoflourescence                                                 Disapproved

            @'@31     -Hemodialysis Training Program                                                                               Approved      but      Unfundec

            "34
                      -Film on  "Care of  the Colostomy Patient"  for Patient  Instruction                                         Deferred       for
                                                                                                                                   Additional           Informatic


                      -National       Medical       Association        Foundation        Nursing                                   Approved      but      Unfunde@
                      Home Development

                                                                                                                             DRMP/GRB
                                                                                                                             5/27/70







                             SUmmARY OF REVIEW AND CONCLUSION OF
                                  JUNE 1970 REVIEW COMMITTEE

                                                              icAL PROGRAM
                     METROPOLITAN WASHINGTON D4C. REGIONAL MED
                                       RM 00031  7/70.1
                       FOR  CON.SIDERATION tY JULY 1970 ADVISORY COUNCIL

             General:  The Committee approved this application with specific conditions;
                    one project was not approved and one was approved at  a  reduced
             level.  Committee's,observations on these projects closely paralleled those
             of the outside reviewers.
             Proieci #36 Diabet s and obe itv Evalua
                      This project which was considered to be  an  applied  research
                      project of activities previously supported by NIR was received
             bnth siasticolly by Committee which cited numerous program concerns and
                 ifie
             n iar   d points in the narrative.  It was questioned whether the
             hyDoth sig on which the program is based is sound enough for translation
             @into an action program and if so, whether it could be effectively evaluated.
             It was noted the total number of children to be examined is not specified
             a it is unclear as,to what happens to the obese children in terms of
             ecific corrective measures and follox,7-up.  Also measures to be used in
             nonob6se children who show prediabetic changes are not described.  The
             program is not structured for the low income group which ne dsa screening
             and referral service.. The letters of endorsement are non-comittal  and
             some Committee members were not assured of the cooperation of the private
             sector upon whom referral and follow-up would depend. The same  members
             !so doubted The value of the educational component which is designed to
             i is6 the index-of-suspicion of physicians, arguing practitioners are
             ware of t e problem And it is questionable how many will make use of  the
             facility.
             in ietAtion to the budget i.t was noted,no mention is made of the division
             of responsibility and duties of personnel.  In the absence of the number
             of children to be studiedi it is im osIsible to estimate the cost per child
                                               p
             examined.  Since there was no information given to estimate the number of
             tests the Gama Counting equipment could do, the reviewers were not convinced
             of the need for the equipment.  The role of the M.D.-ttainee is not clear
             is he 0 post resident or will he be in residency training.  Although the
             pt6je t will probably generate income from charges for services, no
             inf6r ation is provided on this aspect.  Also no plan is presented to phase
             out RMP support.
             @Committee noted and concurred with the Continuing Education and Training
              anch comments that; specific information is lackin2 for the program of
             cntinuinr education for professionals, as well asfor the  children  and
             fniiiies; no information is provided to evaluate feasibility, no mention
         I   i  made of existing resources and the budget reflects the lack of staff -
             Ifo -the continuing education component.
             P tnmmp-ndation:  Non Approval I - No DRMP Funding Recommended.





               ROPOLITAN WASHINGTON D.,C.               -2-                RM   00031   7/70.1
               egional Medical Program

                ect #37 - Early Detection of Chronic Obstructive Pulmonary Disease.

              itique: Committee  and  the  Ad  Hoc  Cardiovascular  Panel  were  in  basic
                        agreement  regarding  this  project.  Both  noted  there  is  un-
              .estioned need to improve the effectiveness of the unaffiliated practicing
              .ysician in  the  detection  and  treatment  of  chronic  obstructive  pulmonary
              sease. It  was  also  recognized  that  this  project  is  designed  to  improve
              rvices to the serious needs of ghetto patients.

               would seem, however,  that  the  staff  might  train  mote  physicians  per
              ar and could provide  some  follow-up  in  the  offices  of  physicians  as
              eded. It is not  clear  how  baseline  data  will  be  obtained  for  later
              aluation of success  and  although  clinical  research  is  suggested  as  a
              ans of evaluation, no plans are included.  The need for evaluation of
              ysicians' response  and  benefits  to  the  community  are  recognized  but
              e forms  are  extensive  and  vague,  and  the  procedures  need  clarification.
              e six-hour course is not spelled out, making it impossible to evaluate
              e educational design.  The request to purchase Vitalors to be given to
              ysicians  as  an  incentive  to  participate  was  considered  inappropriate  in
              at it would set a precedent that would initiate a flood of similar
              quests.  Some doubt was expressed that a full-time laboratory technician
              d a full-time equipment maintenance specialist is justified, particularly
              e latter,  since  Vitalors  are  subject  to  little  breakdown.  Plans  for
              asing out RNP support is not in evidence.

              !commendation:   Approval I - at the  reduced  level  of  01  -  $38,477,
                               02 - $40,618, 03 - $44,928 with the following conditions:

                               1)  No support for Vitalors
                               2)  Justification of maintenance technicians
                               3)  Clarification of evaluation techniques


              IMARY OF RECOMMENDATIONS


              ,.oiect Title  and            Recommendation         01       02        03     Total


              16 -Diabetes and Obesity      Non-Approval I          -0-     -0-       -0-      -0-
                  Evaluation and Pre-
                  vention Program
              @7  Early Detection   of      Approval  I  at      $38,477  $40,618     $44,928  $124,023
                  Chronic Obstructive       reduced   level
                  Pulmonary Disease         with conditions

                  Total Application         Approval   with      $38,477  $40,618     $44,928  $124,023
                                            Specific Condi-
                                            tions
                John Johnson was not present during the      deliberation of this application

                                                                            DRMP/GRB
                                                                            7/14/70
















            0                                                              0                                                              0










                                                Ml,-,I)LCAL Pl-',OG[@AMS SEI),V@f(;F
                                   Of,' A @,tJPPI,FT4ENIIAL OPERAI'IONAI, (,FAN.[' APPI,ICAI'TON'
                                    (A Privileged Communication)

                      Ri@"(;IONAL --,,IEDICAI, PROGRAM              E,,l 00053 I'/i-,O.l
            -LlitC@ 200                                             June  1.970   Revi.ew   Committee
            111.1  Michigan   Avenue
            East l,arioinF!,, Michigan

            1'ro@,rani Coordinator:  Albert E. HeListis, M.D.
            Requested              lst Yr.          2nd   Yr.         3rd   Yr.         TOTAL
            I)irect Costs           897,822     $     812,104     $     806,156         $2,516,082
            Indirect Costs           134,053          192,340          204,49?-               530,885


                                   I O 31., 8 7 5 $1@,004,4li4      $1,010,61,8         $3,046,967
            I] i.s t-ory: The @li.ciiig,.in Associat@iori for Pegional Medical Programs was awarded
                        i.t@s initi-al planning grant of $1,040,639 during June of 1967.  The
            grant  supported  a   central   planning   staff   qnd   separate   subsidiary   planning
            groups.   These    were:
               1) Michigan State Department of Public Health (continued support for
                   this agency not requested after the first year).

               2) Michigan. State Universitv Medical. School.

               3) Iklayne Stite University Medical School.

               14) L@niversity of Michigin Medical School.
            A  consolidated  planning  operational   application   was   submitted   near   the   end
            of  the  first  planning   year.   Following   a   preoperational   site   visit   during
            ,Iune  1968,  the  Region  became  operational  as  of  July  1,  1.968.   TTi   addition
            to  (,oi.-e,  ten  operational  projects  were  supported,  at   $773,567.   The   budget
            period was changed from July 1 to September 1, 1969, at the end of the
            first year.  The second operational year (14 months - 7/i/69 to 8/31/70)
            is  funded  qt  q  total  of  $2,304,595  (d.c.)  -   $1,945,901   basic   and   $358,694
            carryover funds.  This amount supports the Core central planning and
            administrative  staff,  plus  subsidiary   Core   components   in   the   three   medical
            schools.  In addition, nineteen operational projects are, or will be,
            supported  during  this  year   (see   History   Supplement   for   details).
            ilistorical.lv, the reviewers have noted the obviously excellent local.,
            technical.  and  RAC  reviews  that  projects  receive   in   this   Pegion.   In   fact,
            since the Region became operational- (July 1968) only one of a total of
            twentv-six  projects  has   been   recommended   for   nonapproval,   and   this   action
            was  based  on  DRi4l'  policy  involving  the  type  of  training  acti-vity   proposed.
            T)Irect costs only ire noted in the following project descriptions.





                                                                     PM 00053 7/70.1
              @1TC]II.GAN R(@gional .Iedi.cal Program - 2
                                                                     Requested
                                                                     First Year
              1-1 res en t Lal 1 c a t i on: 'I 'his ipl)lic,,itior) requests ,upport
                                   for one renewal and two new  three-
              ye.ir ol-)erllional projects.
              @Project #16 (R) - Surveillance of Electronic Equipment-  $45,701
                                n Special Care Units - Wavne State
              Universi    Detro               This is a one-year renewal
              request to support            eviously approved by C,3uncil
              for one year in the amount of $49,135.  While the total
              program request shown is $86,381, the Region anticipates
                     in grant-related income which will be credited to the
              project.  Thus, the Region requests $45,701 RMP funds for the
              @twelve-month period.
              The specific objectives were:  1) to assess the practices with
              respect to electronic equipment in coronary and intensive care
              units and emergency rooms in Metropolitan Detroit hospitals;
              2) Lo determine the degree to which use of such equipment fulfills
              tile desired medical objectives; 3) to determine the potential
              hazards in the use of such equipment; 4) to determine the need and
              frequency of monitoring of such equipment; 5) to provide pertinent
              safety data about specific equipment to personnel in units surveyed;
              and 6) to determine if incompatibilities in equipment represent a
              significant safety hazard.
              By the end of the first year of operation 25 hospitals will have been"'
              initially surveyed, and numerous equipment discrepancies have been
              identified within each hospital.  Some of the problems found were:
              1) defibrillator output not meeting specifications; 2) defibrillator
              carts were not reasonably ready for use; 3) equipment's internal
              components were not meeting reasonable standards; 4) pacemakers were
              not receiving adeGuate care; and 5) poor design by manufacturer.
              Because of the seriousness of the malfunctions associated with the
              electronic equipment, new objectives have been developed to broaden
              the scope of the new project.  The new objectives are:  1) to establish
              a plan to continue the present project as an ongoing program Without
              the financial support of RMP; 2) to continue and expand the scope
              of tile present project; and 3) to inform the hospitals and medical
              community on the hazards involved in the mi.suse of electronic equipment.
              'I'lie renewal request includes two electronic technicians to be employed
              to better facilitate continued evaluation of the hospital's electronic
              equipment.  it is anticipated that with this additional help they will
              be ,ible to screen 60 new hospitals (urban and rural).  The Region states
              that the response to this offer of service has been much higher than
              anticipated.  Also, the team plans to revisit 75% of the hospitals that
              were visited during the first year.  Electronic equipment in operating
              and emergency rooms, special care and cardiac care units will be included
              in the expanded investigation.  inspection standards and frequencies will






           'IIC!I-IGAiN f@c-gioiial Nledical Prograii,. - 3                00053 -,/70.1

                                                                                 f@e4uestEd
                                                                                 F'Ii@st Year
           i@)e O@t@IbliSlIC-(i for equipment common to most (:Cll Ind (3rit(,rgency
           t-oonis .Coi@tilt@ition will be provided to hospitals purchasing
               (,,i@iii)mei@t, bL]il.ding or remodeling special care units.

           A,, -i iiii-@@ins of informing the medical community on the lilzcirds
                        faulty electronic equipment,  it  is  planned  to:
              (.,on(@lt)ct@ A three-d@iy seminar for physicians; 2) publish four
           @@rticl(!s for inclusion in hot]) regional and national health
                      and 3) produce a fifteen-miriute color f@i.1m.   The
           publicity @iiid distribution of the film will be made through the
                       of the Michigan Ileart Association will will also
           provide assistance in the  development  of  the  three-day  seminar
           for physicians.  Two hospitals, Providence and Sinai, have already
           offered to cosponsor the  seminar  and  will  provide  free  facilities
           and staff support.

           f-oiig-ratige plans include the development of a course on  the  safe
           and effective use of medical and electronic equipment which will be
           included in the medical or osteopathic school curriculum.       Ii-i-
           I)oi.isc@ educational programs to be presented to  community  hospitals
           will also be considered.  These programs wi-11 acquaint the hospital
           ,@t,iffs with the correct techniques of keeping and using safe medical
           electronic equipment.

           Several agencies will be approached in an effort to obtain sponsorship
           to guarantee continuity of support after termination of RMP funding.

           Ilroject l@27 - T)emoiistration of a Comprehensive Health  Care            $505,269
                          Program for the Urban Poor.  Wayne County General
           hospital requests $505,269 through the Michigan R@IP, For the
           first year of a ttiree-year program  to  initiate  a  demonstration
           program of comprehensive health  care  for  the  urban  poor.  This  is
           a revised application. The original.  project  was  reviewed  by  the
           Ativ,tisL 1969 Advisory Council, and approval of planning funds in an
           amount not to exceed $40,000 for each of two years, was recommended.
           The Council I-)elieved the project should be  recast  with  specific,
           clear objectives and methods of procedure; and should include
           information pertaining to the following points:

              1) (oiicrete diagnostic, treatment and fol'lowup procedures should
                 be set forth and documented;
              2') (:tlrreiit demographic inforrTiati-OTi as it relates to the target group;
              i) An oijtline showing a  more  sophisticated  screening  program;
              @'4) A realistic, cooperative, d,-tt@.i-gatl)ering program;
              ')') A cL(,,irl.y written commitment  from  relating,agencies;
              6) A concrete commitment From Wayne County regarding support
                 after termination of RMP funds;
              7') A method of handling fee,-, gener@it@ed throti@h project activities,
              9) A complete, clear training program for "aides" and statements on
                 the intended use of personnel after the training period; and
                 A clear statement of the value of tfiis activity over the existing
                 programs for the target Population.




           ,,,IICIII(;AN Regional Medical Program     - 4                  00053 7/70.1
                                                                                  Requested
                                                                                  First Year
           '['lie revised proposal is for the development of  a  comprehensive
           health care clinic (including detection, diagnosis, treatment
           and followtip procedures) with the outpatient department of
           Wayne County (;eneral Hospital. The  major  impact  will  be  directed
           to the care of the medically  indigent  population  in  Wayne  County.
           IF lie project is designed to compare  two  systems  of  health  care,
           both to operate concurrently in the outpatient department during
           the ttiree-year project period. The  first  system  refers  to  the
           episodic care system (processing of patients in the same maiiner
           used for years, except that  every  alternate  patient  will  be  referred
           to the second system).  The  second  system  is  aimed  at  establishing
           a comprehensive care  system  involving  an  automated,  computerized,
           mttltipliasic screening  program  and  followup  procedures.  The  project
           plans to utilize, as  much  as  possible,  nonprofessional  personnel  who
           will be expected to obtain employment in the operation of the
           Comprehensive Health Care  Clinic  after  completion  of  their  training.
           currently there are  43  separate  clinics  operating  in  the  outpatient
           department  of  Wayne  County  General  Hospital.  The  outpatient  visits
           have increased from 10,000 visits  in  1950  to  about  76,000  visits  in 1969.
           The applicant describes three p,overty-type target areas to'be served by
           this project:  1) Cit  of Inkster - located a block from the hospital
                                 y
           has a population of 37,000, of  which  42.3%  are  nonwhite;  2)  Ecorse
           located a few miles from  the.hospital  -  has  a  population  of  17,238;
           (,the community's nonwhite populatioi-i is estimated at 33.3% (99% black);
           and 3) Ronit-ilus Township (located a few miles from the hospital) has a
           population of 17,000, of which 16% are nonwhite.
           Lt is planned to process four groups of patients through the Comprehensive
           Care Clinic.  The  four  groups  are:  1)  every  alternate  new  indigent
           patient admitted to  the  clinic  (sixty-five  are  expected  weekly);
           2) everv alternate clinic  patient  who  has  not  had  a  comprehensive
           health evaluation for over  a  year  (two  hundred  and  fifty  expected
           X,7eekLy); 3) apparently "healthy" individuals referred from Wayne County
           OEO, Senior Citizen's and other similar community groups (one hundred
           and fifty expected  weekly);  and  4)  every  alternate  patient  admitted
           to the hospital who is not acutely ill.
           Sc,-eeii@@tig tests, examinations and procedures will consi.st  of:
           anthropotiieti-y; a twelve-lead electrocardiogram; chest x-ray;
           mammography; pelvic  examination  (including  a  pap  smear);  oral  and
           clent@il inspection; visual acuity  and  tonometry;  photographs  of  full
           and side  face;  spirometry;  audiometry;  blood  and  urine  specimens.
           The Region states that during the local review of this proposal, the





                   R,-,giollii m(-@dicil, Ilrogram   - 5                00053 7/70.1

                                                                               l@ (-@ (I I I ('!@ t@ e (I
                                                                               first Year
          i-(@viewei-s I)c-l,ieved that all of the points rai.sed by the RMP,"
                    I)ad been satisfactorily covered in  this  proposal  with
          the exception of the commitment of Wayne County  to  carry  on  the
          activi-ty after termination of RMPS funds.  The major portion
          of the requested budget is in the categories  of  personnel  ($173,094),
          equipment ($163,175), alterations  and  renovations  ($91,000)  and
          "other."  "Other" includes rental cost for a computer ($60,000).
          Second Year:  $454,574            Third Year:  $477,459
          I)roject 4@28 - Proposal for the Southeastern Michigan ReRio-nal       $346,852
                        Cancer  Program.  Wayne  State  University  requests
          $346,852 through the Michigan Regional  Medical  Program  for  the
          first year of a three-y6ar proposal which is to improve the care
          of cancer pati-ents in a tri-county area, by  providing  a  clearly
          identified and publitized network of cancer consultants in nursing,
          medicine and social service.  This is the Region's first cancer project.
          The project proposes to  establish  cancer  consultants  throughout
          the fri.-county area (Wayne, Oakland, and Macomb Counties) to increase
          the availability of expertise in cancer management to practicing
          physicians.  A Central Teaching Group of Cancer Experts from Wayne
          State University will serve as faculty  for  training  the  cancer
          consultants and for developing "guidelines for management of patients
  is                              11
          with malignant disease.
          The cancer consultants will be identified and reappointed by the
          Project Director annually and will  have  the  responsibility  of:
          1) implementing a monthly tumor board in their hospitals; 2) implementing
          and attending clinical teaching conferences in their own hospitals;
          3) attending the monthly conferences of the Central Teaching Group;
          and 4) providing consultation (on a fee-for-service basis) to
          physicians and furnish information on current management and
          evaluation standards and therapy recommendations.
          An area-wide cooperative program among radiation therapists will be
          developed to provide needed services and to improve the scope and
          quality of the therapy offered.
          All pathologists in the tri-county area will  be  given  an  opportunity
          to become active participants in pathology slide  seminars  to  be  held
          at two hospitals (St. John and Wayne State).
          A two-week cancer educational program will be provided (maximum of two
          per year) which will enable key nursing personnel throughout the
          tri-county area to gain the necessary knowledge and skills to effectively
          provide cancer nursing care and to teach other nursing personnel.  The
          establishment of hospital nursing units primarily devoted to the care
          of cancer patients requiring aggressive nursing care, will be encouraged.





                                                                     R-,,i 00053 7/70.1
           @IICIIIC;A'i Regional @tedical Program      6


                                                     uraged to work toward the
           Each tri-count@y area hospital will be enco
           establishment of a mandatory Papanicolaou cervical smear requirement for
           women admitted to the hospitals.
           I'he project proposes to demonstrate the feasibility of cooperative
           utilization of social workers in hospitals with less than 250 beds.
           A referral center telephone service will be made available to  answer
           such questions as where to go for financial assistance in  purchasing
           costly drugs or where to obtain a bed for home care.
           Diagnostic/therapeutic baselines (to be used as aids) for selected
           malignant diseases will be developed and will be disseminated to
           practicing physicians in the tri-county area.  The Project Director
           will have overall responsibility for evaluating ongoing and  terminal
           program accomplishments. Terminal evaluation of the extent  to  which
           program activities have improved patient care will consist of physician
           evaluators who will review all available records, x-rays, and tissue slides
           of two patient samples selected so as to permit generalizations.  A
           systematic quantitative and qualitative analysis of all preceding
           project evaluation data will also be included in the terminal evaluation.
           $219,422 of the total request of $346,852, for the first year, is for
           personnel.  $74,770 of the request includes stipends for the cancer
           consultant  mass program mailings to area physicians, Advisory Council
           luncheon conference costs and maintenance of off-campus office.
           Seco,id Year:  $357,530           Third Year:  $328,697




         MICIIT.(',AI4 BEC.LONAL MEDICAL PPOGRAM   - 7 -                   RM 00053 7/70.1
                                           HISTORY SUPPLEMENT
          IIISTTNC OF CIIRRENT ST           E & OPERATIONAL PROJECFS IN MARMP

              A - F-,NDED PROJECTS
          PROJECI@  qlq'LE                                                  AMOUNT SUPPORTED
                                                                            THROI:GH 8/31/70
                                                                           BAS IC  CARRYOVER
              I*      Central Planning & Administrative Staff
                      (East Lansing & Subregions)                       $253,080    $22,000
              3       Coordinated Data Collection and Analysis:
                      Planning for Automation of Multiple
                      Screening, MPH                                     286,487       --
              4       Heart Association, lbdel CCU                       103,590     50,250
              5*      MSU, Planning Office                                228,568      --
              6       MSU, Hypertension Clinic                             52,534
              7,',    U. of Mich., Administrative Secretariat              70,444
              8       Postgraduate Nursing Educ. - U. of Michigan          96,315
              9       U. of Mich. - Drug Information and
                      Therapy Analysis                                     78,783      2i$200
              II      U. of Mich. - Medical Care Evaluation               100,292      22,288
              12      School of Dentistry Program - U. of Mich.            31,636      --
              13      Survey of Physicians' Attitudes - U. of Mich.          --        57,521
              14*     Wayne State Univ. - Planning Office                 139,879      4,290
              15      Zieger-Botsford Hospitals - Survey and
                      Continuing Physician Education                        64,840     10,100
              16      Wayne State Univ. - Surveillance of Electronic
                      Equipment in Special Care Units                       13,211     39,855
              21      Michigan Heart Assoc atioii    Public                  --        65,038
                      Information Project.
              22      Development of a Cardiovascular Center,                          34,440
                      Mercy Hospital, Benton Harbor




               *Cote Planning




         MICHIGAN  REGIONAL  MEDICAL   PROGRAM          8                   RM 00053 7/70.,l
           A   FUNDED  PROJJTECTS  (continued)
                                                                                     '@ORTED
                                                                           AMOUNT SUP
         PROJECT  TITLE                                                     THROUGH 8/31/70
         NLIMBER
                                                                          BASIC    CARRYOVER

                       onstration of    Compr' ensive Hea
          23       Dem                     eh           Ith Care for
                   .the Urban Poor - Wayne County General Hospital                 $ 319712
           25      Innovative Approach to    a Continuing Medical
                   Education System Based    on Existing Satellite
                   Hospital Concept                                        40,512
                                               SUBTOTAL                $1,560,171   $358,694
             B  APPROVE6 - UNFUNDED PROJECTS                           $  a85,730
                   (Note:  DRMP is in the process of awarding
                            $385,730 - annual base - to partially
                            fund the following approved,, unfunded projects)
           17        Stroke Base Center - Wayne State
           18        Development of a Comprehensive Attack on    the
                     Problems of Stroke - Wayne State
           i9        Stroke Demonstration Unit at Detroit Osteopathic Hospital
           20        Central Michigan Comprehensive Stroke Project
           26        An Experimental Continuing Education Program for
                     Small Inner-city Hospitals

                                                   TOTALS               $1,945,901  $358,694

             C   DISAPPROVED PROJECT

           PROJECT  TITLE
           24        Nuclear Medicine Technician Training - Hackley Hospital

             D    DISCONTINUED PROJECTS
             2       Michigan Department of Public Health - Planning
           10        Nonprofessional Staff Utilization      Wayne State University


                                                                                     DRMP
                                                                                     4/30/70'








                                                                A  Privileged   Communication



                               SUKZMY OF REVIEW AND CONCLUSION OF
                                    JUNE 1970 RE-VIEW COMMITTEE


                                MICHIGAN REGIONAL MEDICAL PROGRAM
                                          RM 00053  7/70.1

                         FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


              General:  The Committee recommended that this supplemental operational
                         application which requests $2,516,082 (d.c.o.) @or a three-
              year program period by partially  funded  at  $1,483,003  (d.c.o.)  to  support
              Project #16 for one year (renewal) and Project  #27  in  the  time  and  amount
              requested  (three  years).  Committee  further  recommended  "non-approval  -
              revision required"- for Project #28 for  the  reasons  as  set  forth  below.
              Once Again as in past reviews,  the  Committee  commented  on  the  excellent
              local review of individual project proposals which are submitted from
              this Region.


              Project #16R -.Surveillance of  Electronic  Equipment  in  Special  Care  Units
                              Wayne State University

              Critique:  Members of the Committee were very pleased with the       progress
                          made thus far in  this  project.  The  Review  Committee  concurred
              with the Ad Hoc Cardiovascular Study Panel that  the  need  for  this  type  of
              service has certainly been demonstrated  by  the  results  obtained;  that  the
              objectives are clear and well  defined;  that  the  procedures  utilized  are
              apparently adequate; and the budget is modest.  A.ccordi   ng to the  appl.i-
              cant, a plan has been devised to  continue  and  develop  the  present  project
              as an on-going program without financial support from RMP after this year.
              It was noted that the project is beginning to acquire national recognition.
              The reviewers agreed with  the  study  panel's  unanimous  recommendation  that
              the project is technically sound, capably directed and recommends that
              it be continued in time and for the amount requested.

              Recommendation:  Approval'in time and for the amount requested.

              Direct Costs Only:            Ist Year            -2nd Year             -3rd Year
                                            $45,701          Not requested         Not requested


              Project #27 - Demonstration of A Comprehc,,nsiv,c-- Health Care Prc)@rii@t for
                             the Urbaii Poor

              r@iti@uc:  This is a revision of an application which was originally
                          reviewed during the April--Ilay 1969 Revic-i,, Cycle, i.ii which
              this proposal was one of four proposals to be included in a. technical s-,-"-e
              visit. Foll-o@@7ing a July 15, 1969; site visit, the August 10,69 Coi-irici-I..







              Michigan RMP                       2                   RM  00053   7/70.1


              recommended $40,000 for each of two years to  continue  planning  of  the
              proposal. In addition, nine specific  points  were  raised  which  Council
              believed needed clarification.

              The reviewers believed this proposal satisfactorily   relates to all issues
              raised, with the exception of the current  demographic  information  on  the
              .target population and a commitment from Wayne  County  regarding  support
              after termination of MM funds.  Members  of  Committee  believed  that  more
              detailed demographic information would have been  helpful  in  the  review.
              Also, they reAli,zed that it is politically unrealistic to expect the
              present Board of Supervisors to commit funds  three  years  hence,  although
              the Board's interest in the services to be provided were noted.

              During the review,, the Committee raised some questions  and  issues  which
              they believed the Region should try to resolve.  These were:

              (1) It was difficult to determine from the  written  application  to  what
                  extent the people that are affected by  the  proposal  were  actually
                  involved in the planning of the program;

              (2) The obligation to RMP to purcl-iase, install and maintain  costly  and
                  fixed equipment; and

              (3) Evaluation procedures were considered inadequate,   although  a  cost-
                  effectiveness factor may be determined at the end   of  three  years.

              it was noted that the Michigan School of Public Health   plans to  mal@  use
              of the data obtained. In recommending  approval,  the  Review  Conmiittee
              recommends that a condition of approval be that  the  applicant  seek  more
              participation from the target population and suggested that this be
              accomplished through the establishment of a  subcommittee  on  Health  Care
              of the Poor. it was further recommended  that  the  subcommittee  be  well
              represented by consumers of health. services from the target groups.

              (An Ad Hoc Committee member, a Program Coordinator, abstained in the vote
              on this proposal. He commented that'he  failed  to  understand  how  this
              project can be called comprehensive care rather than multiphasic screening
              since the patients in the study will receive treatment from the same sys-
              tem as the control patients will. Ile further  suggested  that  the  follow-
              up period is insufficient for study and voiced his  concern  of  the  lack
              of community input into the project.)

              Recommendation: Approval'i.n time and amount  requested  subject  to  the
                               condition  outlined above.

              Direct Costs @l-_:     lst Year             2nd Year             3rd   Year
                                     $505,269             $454,574               $477,459






              Michigan KT                         3                  RM  00053  7/70.1


              Project #28 - Proposal for the  Southeastern  Michigan  ReRional  Cancer
                             Program

              Critique: This is the Region's fir4st cancer proposal  and  is  to  improve
                          the care of cancer patients in a tri-county area by providing
              a clearly identified and publicized network  of  cancer  consultants  in
              nursing, medicine and social service.  A survey indicated that the level
              of practice regarding cancer management is outiiioded by about  ten  years.

              Members of the Review Committee believed that  the  concept  of  training
              cancer consultants is naive (if a physician is an oncologist,  lie  is  a
              cancer consultant). It was difficult  for  the  reviewers  to  understand
              why be should be paid-a per them to do what he  should  or  probably  would
              do anyway. Additionally, it was believed  the  requirement  that  all  hos-
              pital admissions have "pap" smears appeared.to  be  an  expensive  duplica-
              tion. A question was also raised  regarding  the  value  of  establishing
              cancer guidelines for this small geographic area.  There was concern about
              the experience the proposed project director has  had  as  an  educator.

              In recommending non-approval, the reviewers believed that the proposal
              should be recast to include much more planning of the educational aspects
              as well as concrete phase out plans, with a greatlv -reduced budget.
              Phasing of the program was also suggested.  It  was  suggested  that  the
              Region utilize medical education evaluation  consultation  at  Wayne  State
              University and that the RMPS Contin  uing Education and  Training  Branch
              staff provide assistance in this effort.

              Rdcommendation:  Non-approval II - revision required.



                                    SUMMARY OF RECOL@ENDATIONS



              Number          Title                       lst Year      2nd Year     3rd Year

              #16R      Surveillance of Electronic        $45,701     Not requested  'got requested
                        Equipment in Special,,Care
                        Units

              #27       Demonstration of a Compre-        505$269       $454,574     $477,459
                        hensive Health Care Program
                        for th e Urban Poor

              #28       Proposal for the Southeastern      Non--approval II - revision required
                        Michigan Regional Cancer
                        Program

              TOTAL                                       $550,970      $454,574     $477,459






              Michigan RMP                       4                  RM 00053  7/70.1


              Year                             Total Direct Costs


              01                                  $   550,970

              02                                      454,574

              03                                      477,459

                                 TOTAL             $1,483,003












































                                                                   DP,MP/C@RB  7/13/70

















             0                                                                                                                             0












                                 REGIONAL MEDICAL PROGRAMS SERVICE
                       SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                     (A Privileged Communication)

                MISSISSIPPI REGIONAL MEDICAL PROGRAM                     RM00057   7/70.1
                2500 North State SLreet                                  June 1970
                Jackson, Mississippi  39216                              Review   Committee

                Program Coordinator:  Guy D. Campbell, M.D.

                Requested
                Program
                Period             Ist  Year      2nd  Year           3rd  Year      Total
                Direct Costs        $520,713       $401,609           $420,679       $1,343,001
                Indirect Costs       194,962        160,472             169,082         524,516


                TOTAL               $715,675       $562,081           $589,761       $1,867,517

                HISTORY:  This Region received a two-year planning    grant beginning
                Julyl, 1967; $322,845 the first year and $505,932 the second.  The
                first year award was supplemented in April 1968 by $131,361 to begin an
                earmarked two-year Comprehensive Stroke  and  Detection  Center  (Project  #I).
                The second year planning award included  $122,610  for  the  second  year
                continuation of Project #1.  A Supplement of $142,675 (earmarked) was
                awarded the second year for a Training Program in Diagnosis and Treatment
                of Chronic Pulmonary Disease (Project #2).

                Following the review of the initial operational application by the
                Review Committee in April, a site visit  was  made  the  following  month
                to assess the Region's  ability  to  assume  operational  status.  The
                shocking lack of resources contrasted  with  the  tremendous  me  ica  care
                needs impressed the site team.  The  shortage  of  health  education  resources
                outside of the University Medical Center is a serious problem which
                cannot be solved overnight and will influence the degree of quality
                medical care possible in this Region for years to come.  But the site
                v@sitors were impressed with the commitment of the staff, participating
                organizations, and RAG in  the  Regional  Medical  Program.  The  site
                visitors felt that Mississippi had to have operational funds in order
                to begin this important task of  effecting  the  facility  of  care.  The
                May 1969 Council  approved  operational  status.  The  first  operational
                award included Core and nine  projects.  One  other  CPR  training  project
                was approved, but funding was deferred  until  Council  policy  was  clarified.

                During the December 1969 meeting,  Council  reviewed  and  approved  a
                supplemental renewal application of Project #1 for three years and three
                months.  Subsequent to this action, the third period of the current award
                was extended from July 1, 1969 - March 31, 1970 (9  months)  to  July  1,  1969




            MISSISSIPPI Regional Medical      -2-                  RM00057 7/70.1
             Program

            June 30, 1970 (12 months) to be sustained by anticipated unexpended
            current funds.  Future support for three years is subject to fiscal
            restraints in FY 1971.
            For ease of reconciliation, please refer to the attached "Review and
            Funding History."
            PRESENT APPLICATION:  This is a supplemental ap lication for support
                                                            p
            of two new projects and one renewal, each for  three  years.  They  will
            be based at the University Medical Center, but  are  action-oriented  at
            the peripheral community level.
                                                                              Requested
            Pro'ect #2R -                   in Diagnosis and Treatment       First Year
            of Chronic PulmonarV Disease                                       $323,730
            This is a request for renewal of a two-year program which   began as a
            feasibility project during the second planning year.  The   Council,
            during its review of the initial application in May 1968, believed  that
            the proposal was well presented and in a Region needing better medical
            care. There was some question as to tenure  of  commitments  and  justi-
            fied level of support. Deferral for a  site  visit  was  recommended.  The
            site visitors, September 1968, observed that the  Region's  capability  was
            not then adequate enough to undertake all aspects of the proposed program.
            The visitors were also concerned about the weakness  in  the  evaluation
            process, particularly the absence of baseline data, against which progress
            could be measured.  During the November 1968 meeting, Council recommended
            approval for two years in a reduced amount of  approximately  half  that
            requested.
            Following a favorable report of a site visit in May, 1969, Council
            recommended approval for continuation of the project in the second period,
            including $72,000 for needed remodeling of facilities.
            A continuation application for the third period of the current grant
            (July 1 - December 31, 1970 - 6 months), is expected in  the  near  future.
            The level of support requested for three additional years'renewal
            beginning January 1, 1971, is considerably less than the amount requested
            for the same period of time in the original five year proposal.
            Current education and training programs include: 1) long  and  short  term
            training activities for physicians, nurses and  allied  health  personnel;
            2) mobile demonstration seminars for outlying  hospitals;  3)  cooperative
            programs for pulmonary therapy aides; and 4) implementation  of  a  formal
            four-month training program for pulmonary therapy aides.  Other activities
            include: 1) demonstration of improved health care of  children  and  adults
            with pulmonary disorders, particularly home care programs; 2) development
            of reproducible bacteriological surveillance techniques for therapy
            equipment; and 3) development of screening procedures for early detection
            of chronic airway obstruction.





              MISSISSIPPI Regional Medical      -3-                 RM00057 7/70.1
                Program


              As reflected in the increased budget, five new  programs  are  planned.
              In the development and demonstration of improved health care to      I
              patients with chronic pulmonary diseases, a  special  pediatric  cliric
              will be conducted once each month. This is  in  addition  to  the  current
              cystic fibrosis clinic which meets two half days per month.  This clinic
              and laboratory will also be part o@-' the facilities used for the project's
              continued education  and  training  activities.  Bacteriological  studies
              will be undertaken to evaluate different practices for cleaning
              inhalation therapy equipment. An internship  program  (6  to  12  months)
              including evening seminars will be offered to graduates of approved
              schools of inhalation therapy.. The efficacy of the ambulatory home
              program is to be evaluated. By use of a  mobile  unit  van,  included  in
              the equipment budget, demonstration seminars  to  peripheral  hospitals
              are to be offered each week, an anticipated annual  increase  from  150
              to 500 participants.

                            Second Year $21E),006      Third Year $219,179
                                                                              Requested
                                                                            First   Year
              Project #13 - Emergency Nursing in Critical Illness               $35,420

              The purpose of this project is to upgrade the quality  of  nursing  the
              critically ill, emergency and day-to-day care.  In tune with this
              objective, a five-day course will be offered to 60 nurses annually.
              The budget indicates that twelve courses will be held each year,
              approximately five trainees per session.  Mindful of the need for
              additional training of nurses in small hospitals, the courses will
              initially be limited to nurses who have close contact with extreme
              emergency and critically ill patients.  Enrollees  will  be  required  to
              return annually for a one-day conference for updated information and to
              review individual problems.  Program assessment includes pre- and
              post-testing, on-the-job logs by trainees,  on-the-job  observation  by
              a project facility member and evaluation of  trainees  by  their  hospital
              administration.

                            Second Year $36,946        Third Year $39,455
                                                                               Requested
                                                                             First Year-
              Project #14 - Comprehensive  Renal Training Program               $161,563

              This is a recast of Project #12, same title, which was funded in a
              greatly reduced amount for a one-year trial period for further planning
              and development of the program.  This action by Council, May 1969,
              followed a site visit that same month.  The  site  visitors  recognized
              the need for the activity. However, it  was  believed  that  the  proposal
              was overly ambitious and lacked sufficient planning.




            MISSISSIPPI Regional Medical      -4-                  RM00057 7/70.1.
              Program


            The purpose' of this project is to reduce the gap  between  knowledge,
            and its application.  Utilizing present facilities, training programs
            will be offered to physicians  nurses, te hnicians, dietitians, social
                                          .1          c
            workers, and administrators. Present  facilities  include  the  Artifi cial
            Kidney Unitlthe Renal Laboratory and the   Home Dialysis  Training  Ce nter.
            Other project aspects include testing screening procedures, teletype
            tie-in with a kidney donor data program, tissue   typing training  and
            statewide telephone consultation for physicians.
            Approximately 70% of  the budget is for personnel.  Support is requested
            in most other budget  categories, most significant amounts of which are
            for equipment and travel.
                              Second Year $154,657      Third Year $162,045






              MISSISSIPPI Regional Medical             -5-                RM00057  7/70.1
                Program


                                    REVIEW AND FUNDING HISTORY

              lst Year Planning Award          7/l/67 - 6/30/68               $322,845

                   February 1967  Council (return for revision)
                   March 1967      Site Visit
                   May 1967        Council
              Project #1 (feasibility study - earmarked funds)
              Stroke Detection and Treatment 4/l/68 - 3/31/70 (01-3 mos.)     $131,361

                                   Approved Future Level - Direct Costs

                                         02               03 (9 mos.)
                                   $80,293                 $61,927
              2nd Year Pianning Award          7/l/68 - 6/30/69               $505,932
                                     (includes $122,610 for Project #1 - 02-12 mos.)

                   September  1968  Site   Visit
              Project #2 (feasibility study - earmarked funds)
              Training Chronic Pulmonary Disease - I/l/69 - 12/31/70  (01-6 mos.) $142,675

                                   Approved Future Level - Direct Costs

                                         02               03 (6 mos.)
                                   $167,467                $89,000

              Initial  Operational   Application
              Projects                              7/l/69 - 6/30/72

              May 1969 Site Visit
              May 1969  Council
              August 1969 Council





           MISSISSIPPI  Regional   Medical       -6-                 RM00057 7/70.1
             Program

                                                               Direct   Costs


                                                        Funded           Commitments
                                                          01           02           03

            00 Core Staff                               $306,879   $329,678      $353,488
           *#I Stroke  Detection  and  Treatment(9  Ws.)  62,619       0             0
            #2 Training   Chronic   Pulmonary
               Disease                                  2 00, 2 92 (6 ms) 89, 000    0
            #3 Post  Graduate  Institute   in
               Medical Sciences                          38,509      47,187       45,396
            #4 Recruitment of Health Manpower            70,000          0           0
            #5 Cardiovascular Clinics                    29,018      29,968       30,966
            #6 System  of  Coronary  Units1             1641,586     79,489       81,409
            #7 Lowndes  General   Hospital              Disapproved - No RNP Funds to be Used
            #8 CPR Training                   (9 mos.)   38,988      46,247          0
            l@9 Central Tumor Register                  Disapproved - No RMP Funds  to be Used
           #10 Radiation Therapy                        204,861      78,629       762898
           #11 Regional   Neurology   Clinics            67,494      66,186       68,909
           #12 Renal Disease Training                    46,321        0             0
                                            Totals    $1,229,567   $766,384      $657,066

              Staff action on 2nd year continuation application.

           First  Supplemental   Operational   Application

           December 1969 Council
           #lR Stroke Care Demonstration and Teaching 4/l/70 - 6/30/73 (3 years -
           3 months). Subsequent to  Council  approval,  the  current  02  period  was
           extended from July 1 - March 31, 1969 to July 1, 1969 - June 30, 1970
           with no additional funds (to be sustained with current unexpended funds).

                                      Approved Future Level-
                                            Direct   Costs

                                01                02                 03

                            $119,803          $131,094           $141,623











                                                                         DRMP
                                                                      6/3/70







                                                           A Privileged Communication

                           SUMMARY OF REVIEW AND CONCLUSIONS OF
                               jUNE 1970 REVIEW COMMITTEE


                          MISSISSIPPI REGIONAL MEDICAL PROGRAM
                                     RM 00057  7/70.1

                    FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


            General:  The Review Committee recommended that this Supplemental opera-
                      tional Application requesting $1,343,001 (d.c.o.) for three
            years, be partially supported at $378,821 (d.c.o.); $213,420 the first
            year, $125,946 the second and $39,455 the third.

            Throughout the review of this application, the Committee was mindful of
            the dearth of medical care in Mississippi and the lack of adequate medi-
            cAl facilities and manpower.  Although the recent second year continuation
            application indicated the Region has made some progress 'in tackling its
            problems the staff reported, the Committee expressed concern that the
            MRMP does not seem to be addressing "real world" priorities And the cate-
            gorical emphasis may have attributed to this problem.  It was believed
            that there is great need for RMPS staff assistance in helping the Region
            study its representation on the RAG so that basic health needs of the
            people are considered in setting priorities.


            Project #2R - training Program in Diagnosis and Treatment of Chronic
                          Pulmonary Disease

            Critique:  The Committee reviewed the history of this two-year project
                       for which renewed support ($752,915 d.c.o.) is requested for
            three Years.  Previous site visit and Council actions outlined in the
            history summary were noted.  It was believed that though needs are well
            documented, evaluation procedures are limited and reported accomplishments
            are meager.  While the bacteriological surveillance of aspects would prob-
            ably go well, there is some question about the capability of carrying out
            meaningful education.  The shortage of physician and allied health resour-
            ces in Mississippi is well known6  M@ programs are moving in categorical
            areas and perhaps the immediate needs are for more comprehensive Activities.
            The question arose as to whether pulmonary training is a major unmet
            health need in Mississippi.  Regardless of the prbject's priority status
            in the MRMP, the Committee felt that not enough documentation was pre-
            sented to justify approval of the Amount nor the period of time requested.

            Recommendation:  Approval at the current annual level ($178,000) for 18
                            months.  The Region should be given assistance by the
            Continuing Education Branch staff of RMPS to assure that the next continue,
            ation application includes progress defined in specific terms.






         Mississippi RMP                   2                        RM  00057  7/70.1


         Project #13 - Emergency Nursing in Critical Illness
         Critique:  The Committee agreed with the comments provided by  the  Continu-
                    ing Education and Training Panel. The design  in  general  is
         well written and developed and the direction is a helpful one  for  this
         Region. However, there is no indication of  preassessment  of  learner's
         knowledge (especially in physiology and chemistry) necessary  to  compre-
         hend the course co-,itent. There is some question of the  appropriateness
         of course content for rural nurses. There is not  enough  indication  of
         nursing participation in the development of the program, of  nurse  teach-
         ing in the course, or of the nature of  follow-up  support.  Objectives
         are stated well in program terms, but learner behavior reference  is  not.
         There is a need for more evidence of interest in  utilizing  co-trainees'
         new skills from hospitals and their medical staffs.  Evaluation,  for  which
         there is probably too little staff time allocated, is all in  terms  of
         learner s knowledge and attitudes rather than in behavior.  A  more  mean-
         ingful evaluation might be in terms of the impact of training  on  patient
         care. The budget may be too modest for staff time for  the  secretary  and
         nurse coordinator. There are no specifics presented  about  phasing  out
         or continuing the activity beyond cessation of the grant.  Although
         answers to questions'and concerns are desired, the project was considered
         worthy of support.
         Recommendation: Approval I in the amount requested.  It  is  also  recom-
                          mended that the MRMP be informed about  the  reviewers
         conc(!rns and questions. Specific suggestions: (1)  nursing  faculty  be
         utilized in teaching nursing content; (2) curriculum vitae  for  nursing
         personnel be provided to @S;(3) assurance of  adequate  staff  time  to
         carry out secretarial work, circuit riding and evaluation; and  (4)  docu-
         mentation of commitment of sending hospital's administration  and  medical
         staff to utilize training of students on their return to work.


         Project #14 -
         Critique:  The Review Committee noted that this project grew out of
                    experience with Project #12, same title, which was  funded  in
         a greatly reduced amount ($46,321 d.c.o.) for one year for further  plati-
         ning and development.
         Review comments indicating that the program was feasible  under  certain
         conditions by the Continuing Education and Training Panel  were  considered.
         Conditions included concerns that the physician courses are  too  minimal,
         the nurse course 201 seemed impossible for the time allotted,  and  the
         tissue typing course should be eliminated. The Panel  believed  that  the
         curriculum should be better defined to indicate where all  the  different
         categories of personnel will fit in. Other  concerns  included  equipment
         budget justification; specific information needed about the  number  and
         location of satellite dialysis programs; need for better  description  of







             Mississippi RMP                  - 3 -                      RM 00057  7/70.1


             the trailer dialysis unit, and other types of dialysis  aci  ities,  c  ari-
             fication of fellowship program (e.g., is  this  for  board  certification;
             patient selection criteria needs should be better identified (e.g., will
             patients over 65, for whom medicare will reimburse, be selected over
             younger patients who cannot pay).
             This proposal stimulated a great deal of discussion in terms  of  (1)  tech-
             nical soundness and-feasibility of the application; (2)  the  priority  of
             renal disease program@ in MRMP; and (3) RMPS' role and limitations in
             this area.

             The Committee had the benefit of comments from one  of  its  members  with
             expertise in nephrology and knowledge about the status  of  renal  disease
             management in Mississippi. He stated that Mississippi  seems  to  have  most
             of the five basics needed for an end stage kidney program:  (1) a dialysis
             center; (2) multiple satellite dialysis units; (3) tissue  typing;  (4)  or-
             gan retrieval and (5) transplant facilities.  He also believed t e proj-
             ect director to be capable of conducting  a  successful  program.  It  was
             noted that the trailer dialysis unit is a new innovative aspect that may
             prove to be very worthwhile in Mississippi.

             Some believed that RNP funds for renal disease should be limited to
             training, which is the purpose of this proposal.  The  question  then  arose
             that unless more dialysis facilities are needed and established, why
             train additional personnel?  This question was not satisfactorily resolved.
             Others believed RMP funds should not be used for  programs  in  end  stage
             kidney disease, that there are other greater needs  for  available  dollars.
             The Committee, however, recognized that RMPS had  to  become  involved  in
             renal diseases but on a carefully considered  basis.  They  request  Council
             to spell out a clear policy for RMP funding to guide them.
             The high cost of the proposed program for 240 patients was considered
             in relation to other unmet health needs of more people,  and  the  Committee
             felt that a RAG more representative of all the people in Mississippi
             might come up with a different order of priorities.

             Two motions for recommendations were defeated by  a  narrow  margin.  They
             were: (1) Approval I with conditions cited  by  the  Continuing  Education
             Panel and (2) Non-Approval I.

             Recommendation: Non-Approval II Revision  Required.  This  action  is  not
                               to be construed as encouragement to  submit  a  revision'
             It :Ls strongly recommended that @S staff  assistance  be  provided,  parti-
             cularly regarding the relation of this activity  to  other  health  needs.



   ig






                                                                              RM  00057  7/70.1
           Mississippi RMP                      4


                                SUMMARY OF RECOMMENDATIONS


                                       DIRECT COSTS


                                        01               02              03             Total
           #2R Chr. Pul.
           Disease                   $178,000         $  89,000              -0-       $267,000

           #13 Emerg. Nursing
           Critically Ill              35,420            36,946           39,455        111,821

           #14 Compr. Renal
           Trg.                           -0-               -0-              -0-            -0-
                 TOTAL               $213,420          $125,946       $   39,455       $378,821


































                                                                     DRNP  7/8/70


















             0                                                              0                                                              1









                               REGIONAL MEDICAL PROGRAMS SERVICE
                    SUMMARY OF AN  OPERATIONAL  SUPPLEMENTAL  GRANT  APPLICATION
                                    (A Privile,',ed Communication)



             MISSOURI  REGIONAL  MEDICAL  PROGRAM               RM 00009 7/70.1
             Lewis Hall                                         June 1970 Review Committee
             406 Turner Avenue
             Co lumbia, Missouri  65201

             PROGRAM COORDINATOR:  Arthur E. Rikli, M.D., M.P.H.

             Requested          lst  Year       2nd  Year      3rd   Year      Total

             Direct Costs        $343,253       $223,540         $161,938      $728,731
             Indirect Costs       105,856          81,075          61,554         248,485


             TOTAL               $449,109       $304,615         $223,492      $977,216

             BACKGROUND:  The Missouri Regional Medical Program is beginning its fifth
                          year of planning and its fourth year of operations.  The
             level of funding which the Region has  requested  for  the  year  beginning
             July 1, 1970, is approximately $3.8 million (d.c.o.) of which $.74
             million is carryover  of  une@nded  funds  from  the  1969-1970  year.  The
             $3.8 million includes $2.7 million for projects  and  $1.1  million  for
             core (these amounts are currently under negotiation with staff).
             A complete list of Missouri's projects are included in an attached
             staff observation.  The Region has no approved but unfunded projects.
             The Missouri Regional Medical Program has as its applicant organi-,
             zation, the University of Missouri,  located  in  Columbia.  Dr.  Arthur
             Rikli, who had served as Director of Operations since early 1968, was
             appointed Coordinator in October 1968. The  core  staff,  which  has  27
             positions, includes the Office of the Coordinator, the Office for
             Operations, which administers the projects,  and  the  Office  of  Planning,
             which includes health care studies and six subregional offices. The
             12-member Advisory  Council,composed  of  practicing  physicians,  hospital
             administrators, a lawyer, state legislators, a sociologist and
             businessman, approves the applications and   assists in determining
             program priorities.  An  eight-member  Project  Review  Committee,  chaired
             by the Dean of the School of Medicine at  the  University  of  Missouri,  a
             Central Liaison Committee representative  of  23  organizations  and  three
             area liaison committees assist the Advisory Council in its review
             function. The area  liaison  committees  representing  the  Greater  Kansas
             City, the Southeast Missouri, and the Southwest Missouri areas also
             serve to answer boundary or  jurisdictional  questions  of  project
             proposals. Although the majority  of  the  Missouri  RNP's  earlier








             MISSOUP,L REGIONAL MEDICAL PROGRAM'  -.2-            RM 00009  7/70@.1


             projects are based at the University Medical Center, the Region's
             more recent submissions. have been  based  in  areas  peripheral  to
             the Medical Center - Kansas City, Sikeston and.Joplin.

             The Missouri WV had been encouraged'by DRMP' in 1966 to develop
             an operational program and  it.became  one  of.the  first  Regions  to
             become operational.  It  developed  a  program  emphasizing  a  computer
             and bioengineering approach to improving the delivery of-health
             care. However, in  the  meantime,  changes  in  the  federal  health
             effort and RMP's role in that effort  in  the  last  three  years  and
             the lack of demonstrable  success  of  these  activities  seemed  to
             dictate a change in emphasis.  A  ma  or-pro-ram  site  visit  was  held
             in October i969; the site  visitors  also  believed  that  these  pro-
             jects had not lived  up  to  their  expectations and  noted   growing
             enthusiasm  among  various  Missouri  @   groups for subregional pro-
             grams-. They recommended  that  the  computer  -bioengineering projects
             at the University be phased  out  by  June  1971 and  that  the  Region
             emphasize  commtmity-based  activities.   Review Committee  and   Council
             akreed to the need  for  the  change,  and  made their    recommendations
             for the Region's future funding levels accordingly.

             the  Regio
                      n s funding picture in direct costs for 1969-70 may be
             presented as follows:

                  Computer and Bioengineering,Activities        $2.0  million
                  Subregional Projects                              .6 million
                  Core                                            1.1 million
                                                                $3.7  million
                  Carryover Funds                                 1.1 million
                                                                $4.8  million



             Council's recommendation  for 1970-71 was:

                  For phase out of
                  Computer and Bioengineering Activities        $1.0   million
                  Subregional Projects #25, 26, 27, 29,
                    33 and 46                                      .96 million
                  Core                                            1.1  million
                                                                $3.06 million

                  Council also suggested the Region use         $ .94 million
                  up to approximately $940,000 in carryover
                  funds  for  additional  subregional  activities
                                                                $4.0   million










             Y.ISSOURI REGIONAL NEDICAL PROGRAM -3-          RM  00009  7/70.1



             Inherent in-the phase-out of  the  computer  and  bioengineering
             activities, for which support was not recommended  beyond  June  30,
             1971, was an expansion of subregional  activities.  In  the  grant
             year beginning in July 1971 and 1972,  Council  recommended  that
             approximately $2.2 million and $1.8  million,  respectively,  in
             new funding be available for the approved  core,  new  supplemental
             and continuation projects. Council  stated  that  these  recommended
             levels in no way represented ceilings and that  the  Region  could
             compete for Additional  funding  with  subsequent  applications.

             Other recommendations which national reviewers  made  include:  1)
             expand the membership of the Regional Advisory  Council  to  include
             a more representative group, analogous to the  composition  of  the
             Liaison Committee; 2) differentiate more clearly  between  the  pro-
             gram of the medical school and the program of  the  Missouri  RNP;
             3) concentrate more efforts in the Kansas City  urban  povertv  area
             and delegate more responsibility to the new  medical  school  in
             Kansas City for RNP activities  there.  Correspondingly,  the  core
             office should also make greater attempts to  involve  local  people
             in communities outside Columbia in decisions  affecting  them;  and
             4) take cognizance of continuing education efforts throughout the Region
             rather than concentrating on improving the program of the
             medical school.

             Project #60 - Cameron Health Care System Project.  This          Requested
                           proposal is geared toward improving both the       First Year
             quality and quantity of health services in an established        $108,335
             medical service area.


             The Cameron Community Hospital ia a 58-bed facility located
             in the center of a four-county service  area  in  the  Northwest
             Corner of Missouri. The disappearance of  M.  D.  physicians  from
             rural areas has left Cameron with a staff  composed  entirely  of
             osteopathic physicians. The proposers  believe  that  the  rural
             and attendant professional isolation has contributed  to  the  loss
             of physicians from the area and hope to reverse  this  trend  by
             instituting a better health care system with  the  following  sub-
             systems:  1)  Continuing Education of Physicians and Allied Health
             Personnel involves sending two physicians for  a  one-month  course;
             sending five registered nurses to UMMC for  training  in  intensive
             coronary care; subscribing to weekly videotape  lecture  series  of
             wet clinics with faculty from both  medical  schools;  obtaining
             special training for the home health agency  discharge  nurse  at
             the UMMC; and sending four nurses to the UMMC  for  training  in
             rehabilitation techniques.  2)  Intensive  Coronary  Care  Unit.
             The hospital would need RNP funds for  training  physicians  and
             nurses, as the hospital would supply all  the  necessary  monitoring






           MISSOURI REGIONAL MEDICAL-.PROGRAM -4-            RM 00009 7/70.1:

           equipment and a crash cart.  Eventually the hospital will build an
           addition to house an enlarged rehabilitation unit.and an enlarged
           physical therapy unit and will increase the twb-bed unit to four
           beds.  The hospital will also add a third telephonic ECG link-up
           with  cardiologists in Kansas City. 3) An Ambulance Service is
           needed because  the advent of Wage and Hour Law is precipitating
           funeral  directors' phase-out of such service. As the hospital is
           purchasing the  two ambulances, PM support is needed to supply an
           ECG and  heart-lung resuscitation equipment and supplies.  -Nine
           attendants will  be sent to UMKC for 60 hours of training.  When not
           devoted to ambulance-service, the attendants will be used elsewhere
           in the hospital.  4) Rehabilitation Services  would be made possible
           by hiring a physical Thera-pis-t and training four rehabilitation
           nurs6s who would in turn train aides assigned to the unit.  Because
           dental care is an important part of this service, PM funds are
           requ@sted to purchase dental equipment for the unit.  5) Home Health
           A      ervices would be provided by a nurse who would receive
           training at the UMMC and then function as a discharge-nurse in the
           hospital.
           A Project Coordinating Committee composed of three lay board members
           and three professional staff members will determine policy for the
           project director.  Each subsystem will have a staff member as chair-
           man.  Each of the subsystems will be evaluated both objectively, by
           test scores, cost comparison, mortality figures, etc., and subjectively
           by physicians, nurses, administrators and the community.
           The bulk of the three-year $198,744 request is for personnel ($152,375).
           Second Year:  $54,967                 Third Year: $35,442
           Project #61 - Branson Intensive Care and Rehabilitation Project.        sted
                         This proposal would create within the Skaggs         IFirst Year
           Community Hospital in Branson, Missouri, a comprehensive -         $135,168
           intensive care unit and a rehabilitation unit.  The hospital
           has 59 beds and is located in the Southwest corner of Missouri,
           40 miles from any other hospital.
           The project would "provide a model for demonstrating effectiveness
           of regionalization in establishing new services in a small community
           hospital."  Space will be remodeled to house the four-bed intensive
           care and the rehabilitation units.  Physicians and nurses would
           receive training in cardiovascular care techniques and in physical
           t--dicine in the Springfield Cardiovascular Education and Evaluation
           Project (Project #22).  A physical therapist and a part-time








              MISSOURI REGIONAL MEDICAL PROGRAM  -5-              RM 00009  7/70.1


              occupational therapist would be hired.  Continuing  education  would
              be conducted in regular seminar sessions and through the use of the
              ROCOM Program (a multimedia instructional system produced  by  John
              Sutherland).

              The staff of the Springfield project and the University of Missouri
              Medical Center will be available for consultation  on  establishing
              the program and for evaluation.

              While $23,084 is requested for the first year for equipment and $10.000
              for alterations and renovations, funds are primarily  budgeted  for
              personnel and their training ($91,424). The  third  year's  budget
              is for evaluation efforts.

              Second Year:  $57,620                  Third Year:  $9,000
              Project #62 - Drug Information Central. The UMMC Department of  Requested
                            Community Health and Medical Practice will         First Year
              sponsor this proposal to develop a centralized comprehensive     $99,730
              drug information service that would be available to ail health
              professionals throughout the Region.  This system will serve
              to rapidly furnish drug information on request, supplement
              continuing education programs , save time for health  professionals,
              and provide composite information on drug interaction  and  incom-
              patibilities.
              Operating in conjunction with the Computer FACT (Fast Access to
              Current Text) Bank, various types of drug information would be
              accessible by telephone or mail inquiry, as well as by personal
              visit. Additional access would be possible  through  the  existing
              four-station Telex network (Springfield, Kansas  City,  Kirksville,
              Sikeston).  It would make.available information of practical
              importance in the managment of patients, information  not  currently
              available in any single book, set of journals or  review  articles,
              and information being continually updated and expanded at  a  rapid
              rate.

              During the first six months of operation, D.I.C. Terminals  will  be
              established in six community hospitals.  In the second year they will
              be placed in atleast twelve more hospitals and probably  in  several
              group practices, clinics, and physicians's offices.  During the
              third year, it is expected additional hospitals, clinics, etc., will
              request terminals and be prepared to cover their entire cost and that
              institutions and physicians in neighboring regions will arrange for
              D.I.C. Terminals via negotiations with the Missouri RNP.







         MISSOURI REGIONAL NEDICAL-PROGRAM  -6-             RM 00009 7/70.'l

         Together with computer-developed records, evaluation will be based
         on a questionnaire circulated at si@month  intervals  aimed  at
         determining the number of inquiries received, the number answered
         and the mean time required, and the number of repeat  inquiries
         from other sources in the same category.
         As for continuation of the'Drug Information Central beyond  the
         period of RNP involvement, the Region reports some promising
         preliminary talks with FDA, NIMH, and several other  interested
         organizations.  It also hoped that local institutions and individ-
         ual-  physicians would lend financial support in order to continue
         to enjoy the benefits of the system.
         Second Year:   $110$953               Third Year:  $117,496






























                                                DREP/GRB
                                                5/25/70






                                                                     MISSOURI REGIONAL MEDICAL PROGRAM
                                                                     RM 00009 7/70-1
                                                                     A Privileged Communication


                 STAFF OBSERVATIONS


                                      Actions

                                                                                           STATUS AND
                 PROJECT                                                                   CURRENT SUPPORT
                 #1  - Smithville Community Health Service Program                         Terminated
                 #2  - Communications Research Unit (04)                                   $25,349
                 #4     - Multiphasic Testing (now in Project #49)  (04)                   (67,673)
                 #5     -Mass Screening Radiology (now in Project #49)          (04)       (37,693)
                 #6     -Automated Patient History (now in Project #49)  (04)              (72,880)
                 #7     -Data Evaluation and Computer Simulation (now in                   (94,538)
                        Project #49) (04)
                 #8     -Computer Fact Bank (now in Project #49) (04)                      (107,348)
                 #12    -Operations  Research   and   Systems   Design   (now   in         (32,839)
                        Project #49)  (04)
                 #13    -Populations Study Group Survey       (04)                             20,585
                 #f4    -Automated   Hospital   Patient   Survey   (04)                        36,955
                 #16    -Program Evaluation Center                                         Terminated
                 #17    -Bioengineering (now in Project #49)  (04)                         (52,883)
                 #18    and #30   Core                                                      1,100,000
                 #19    -Automated EKG (now in Project #49)  (04)                          (223,257)
                 #22    -Comprehensive CV Care Units, Springfield                          Terminat(@d
                 #23    -Manual of Services                                                Terminated
                 #25    -Stroke Int ensive Care Unit (03)                                  150,'062
                 #26    -Training Unit for the Intensive Care of the                       156,735
                        Cardiac Patient (03)
                 #27    -Programmed Comprehensive Cardiovascular Care (03)                 12-),417
                 #28    -Tumor Registry                                         -          Terminated
                 #29    -Northeast Missouri Cooperative Stroke Pilot                          67,31-4
                        Project (03)







              MISSOURI @IP STAFF OBSERVATIOiqS      - 2              RM 00009  7/70.1


              #32 - Effectiveness of the Detail Man Approach                   Terminated

              #33 - Continuing Education for the"Healtb Professions            228,098
                     (02)

              #34 - Community Services for Heart Disease, Cancer               Terminated
                     and Stroke


              #35 - Education of. Greene County Residents About                Disapproved
                     Heart Attacks

              #36 - Missouri Cervical Cytology Project (02)                     71,725

              #37 - Southeast Missouri Radioisotope Program    (02)             77,462

              #38 - Homemaker liome-Health Aide Project (02)                   108,198

              #39  - Phor@ocardioscan Project (02)                              34,055

              #40  - ICU and Pulmonary Function Laboratory,                    Returned   for
                     Sikeston                                                  Revision


              #41  - Stroke Prevention and Rehabilitation Program,             Returned   for
                     Joplin                                                    Revision

              #42  - Early Detection of  Cervical  Cancer                      Disapproved

              #43  - Early Diagnosis and Treatment  of  Children                61,831
                     with Diabetes Mellitus (02)
                                                                               Returned   for
              #44  - Cardiac Care and Risk Evaluation                          Revision


              #45  - Lebanon Model Project                                     Returned   for
                                                                               Revision
              #46  - Hi-Blood (02)                                             129,985

              #47  - Core-Continuing Education                                 Returned   for
                                                                               Revision
              #49  - Advanced Technology Project                               917,111

              #50  - Stroke Prevention and Rehabilitation,                      91,819
                     Joplin (01)

              #51  - Intensive Care Unit and Pulmonary Function                 95,983
                     Laboratory, Sikeston (01)

              #52  - Health Careers Program (01)                                62,240

              #53    Early Detection of  Cervical  Cancer                      Disapproved






                            'STAFF.OBSERVATIONS        - 3            RM 00009  7/70.1
              MISSOURI @IP


              #54 - On-Line Diagnostic and Reporting System                       Disapproved
              #55 - Cancer Management and Education                               112,973
                     Optimization (01)
              #56  - Supportive Communication for Satellite Units                 Disapproved
              #57  - Automated Patient History Acquisition                        Returned for
                                                                                  Revision
              #58  - Cardiovascular Education and Evaluation,
                     Springfield (01)                                             127,503
              .#59 - Regional Blood Inventory System                              Disap    ved
                     Total                                                    $3,800,000  1/

              1/ Award includes $3,074,230 new funds and $725,770 in carryover.


























                                                                          GRB/6/19/70








                                                                        A Privileged Cc)iiiinui-iication



                                   SUI,R-IAITY OF RF,,VIEI,l Al\'D COI\TCLUSIO'@i ON
                                        JUNE 1970 I;IEVIET-1 CO@@IITTEE


                                   MISSOURI IEGIONAL MEDICAL PROGI@L
                                              P,M 00009  7/70.1


                            FOR CONSIDEI@TION BY JULY 1970 ADVISORY COUNCIT,



               Cenc,ral:   The @lissouri RMP submitted a supplemental application for three
                           projects requesting $1,185,059 for a th.ree-year program period.
               The  Coiyiinittee  concluded  that  the  application  be  supported   as   follows:
               $33,243  the  first  year,  $36,981@  the  second  year,  and  $39,--t.65  the  third
               year to support Project #62, Dru- Inforiiiati.oii Cei-itral-.      Projects   #60   and
               #61 were disapproved.

               The Coni.@lnittee was rei-ai-ndc-d that previous re-,@ic@@qers  have  encouraged  the
               Region  to  submit   conirtunity-based   activities   and   d(@emphapize   University--
               based projects in computer and bioengiiieeriiig areas.           WI).ile  the  Region
               has  fol-lo-v7ed  this  advice  in  the  present  application  (two  projects   are
               based i - !i.-)spitals in small communities anO. one at the University of
               Missour@@    -1.)artment of Coir@mu.iiity Health and 1.4.cdica.1 Practice),  the  re-
               vie-v7ey@c.1    generally disappointed with the projects.  The projects in
               Brailsoi@i     Caineroi,.i appeared to be  gapfilling  measures  for  the  liospita.  s
               wli e r e   support  was  being  substituted  for  what  the   community   shoul-d   be
               supporting.  Specific criticisms concerning each project fol.low.


               Project #60 - Cameron I-leal-th@ar@Sy@ -,.i  Pro2ject

               r@i.tj,g,ue:  This  request  is  a  potpourri  of  individual  projects   within   one,
                            directed  at  improving  care  within  a  58-bed   hospital   in   the
               northwest  corner  of  @,lissouri.  Because  the   hospital.   is   served   entirely
               by osteopathic physicians  who have not related wel'  to the medical.
               doctors in the area, an additional @iii,,i is the i-Y)iprO -\7ei-ao-,nt of  cooperation
               between these two groups.       In  reviewing  the  educational-   portion   of   the
               project--,, the Continu-1y).g Ed@icati@on and Training Panel concluded that the
               objectives  were  not  stated  in  measurable  terms  and  no  mention  was  riia   e
               of  resources  for  educational  methods.  No   provision   is   made   for   staff
                     or funds and no description of methods is given for evaluation.

               For  these  reasons  and  because  the  project  would  buy  services  with   EL@IP
               funds which the Cc)nri:r@-'LtLec,, fc-l.t the cor,.-,@niuni.ty should be supporting, (I:ls-
               approval- was recor,,@.iTiei@).cled.

               Rec@c)iT).mei-.id-atioi-).: Non-appi-c)v@il. I (no R"@-P funding recommended.







                 Missouri-  l@LT                           2                        RM    00009    7/70.1


                 Project #61 - Brqpsoi-.i Intensive      Care and Relial.)il.itation Lr_)e@-ct
                        IJE@: This project also serves"       a. small  con-Luunity  in  rural  Itissoui-i,
                              but   reviewers   thought   it   was   representative   of   the   ambitions
                 of  a   single   institution,   rather   than   a   truly   regional   cooperative   effort.
                 The  Continuing  Education   and   Training   Panel   believed   that   the   need   for
                 a four-I)ed unit based on 90 patients a year was overstated.   Souie descrip-
                 tion.  of  in-hospital  days,  nature  of   diagnosis,   ages   of   patients   and   use
                 by  ambulatory  patients  would  have  been  useful-   i,i-i   substantiating   the   need
                 for  more  beds.   The   Panel   also   felt   evaluation   could   be   improved:   while
                 the   project   would   measure   effectiveness   in   terms   of   morbidity,   reviewers
                 believed   improvement   in   the   functional   capacity   of   patients   should   also
                 be  measured.  A  more   adequate   description   was   needed   of   how   all   health
                 professionals,   particularly   nurses   and   allied   health   personnel,    would    be
                 involved in further planning and operation of the project.

                 In  ligrit  of  these  technical  criticisms   and   the   lack   of   conviction   that
                 this  project   would   truly   further   regional-j-zatiori   efforts,   the   Committee
                 recommended disapproval.

                 Peconimc@n.dati.on:   1,Ton-approval I (no n@IP funding recommended).


                 Project #62 - Dru  Information Central.
                 @i- i@-u @:  The Committee was satisfied that the project would serve a
                              need for pliysic-,i-an-- by providing  adeclu@i.tc-  updated  drug  ini'o-L'-
                 iiiatioii@ from reliable sources.     I%Thile  the  reviewers  thought   that   the   dial
                 access  system  for  drug  -J-nforniation  night  be  a   useful   tool   in   providing
                 the information, the amount of funds requested seemed high.                     Furthermore,
                 tbb  hospital  pha_-i-.qaci.sts  do  not  seem  to  be  an  integral  part  of  the   System
                 and the Committee felt that their involvement was essential.  Accordingly,
                 approval was recommended at one-third of the requested amount wl.t                  t  e
                 condition  that  the  format  be  revised   to   involve   existing   hospital   pliar---
                 macy mqnl)ower.

                 RecoF,-@Tendation:   Approval I at     the following level with the condition that
                                      the format be    revised  to  include  existin@,   hospital   1)ha-i.--
                                     macy inanpo%7er.

                                01.                            02                             03
                            $33,243                        $36,984                         $39,165

                 Conclusion:     A, total. of $109,392 was i-@ecoli,,j-nc--,riclcd for Project l@62.


                 1.)octor Wi-Iliai,,i I.,IaYE'!'I.- not present dzir-t-ii.2, the deliberation of








              Missouri Pl,[P                     3                  RM 00009  7/70.1



                                                         01              02             03
              Project #60 -- Cameron Hea.1-th
              Care System Project                   Non-approval I - no Rlfi@ funds recommended

              Project #61 - Branson Intensive
              Care and Rehabilitation Project       Non-approval I - no RMP funds recommended

              Project #62   Drug Information          $33,2zi3        $36,984        $39,165
              Central

              TOTAI,                                  $33,243         $36,984        $39,3.65






































                                                                          DP@IP 7/10/70


















          I 0                                                             0                                                              0







                                  REGIONAL MEDICAL PROGRAMS SERVICE
                       SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION
                                         (A Privileged Communication)

           MISSOURI REGIONAL MEDICAL PROGRAM                         RM 00009  7/70.2
           Lewis Hall                                                June  1970  Review  Committee
           406 Turner Avenue
           Columbia, Missouri  65201

           PROGRAM COORDINATOR:  Arthur E. Rikli, M.D., M.P.H.

           Requested:      Ist  Year   2nd Year    3rd   Year  4th  Year    5th  Year  TOTAL
           Direct Costs     $109,596   $179,345      $234,260  $485,531     $526,187    $1,534,919
           Indirect Costs     34,860     55$183        75,133    151,849      167,034      484,059


           TOTAL            $144,456   $234,528      $309,393  $637,380      $693,221   $2,018,978

           HISTORY:  A general history for the Missouri RMP    may be found in the summary
                      (RM 00009  7/70.1).

           The project in the  application  (RM  00009  7/70.2),  entitled  Continuing
           Education - Coordination Project, was originally submitted on May 1, 1969.
           The original application requested $1,384,647 for five years, most of which
           was in personnel.  The 5roposal was divided into three parts: 1) the core
           cooperative activity, 2  the teacher-consultant activity, and 35 the local
           educational coordinator.  A history of the review of.this project is outlined
           in a  Staff  Observation.


           PRESENT APPLICATION
                                                                                      Requested
           Project #63 - Continuing Education - Coordination Proiect.  The            First   Year
                          primary goal of this project is "the improvement of          $109,596
           patient care through the development of a meaningful system of con-
           tinuing education that is built into the day-to-day, week-t@week
           practice of health professionals  of  the  Missouri  Region."  This  propo-
           sal would develop the framework and  linkage  mechanisms  of  a  meaningful
           continuing education system which would  provide  the  bridge  between  the
           agencies and institutions in Missouri concerned with continuing
           education. Its objectives and  methodology  would  serve  to  help  under-
           stand: 1) the current efforts to avoid  overlap  and  duplication;  2)  the
           degree of effort the organizations are willing  to  exert  in  the  future;
           3) the degree to which these same  organizations  will  use  this  project
           to enhance their own activities, as well as support others' activities;
           4) the needs of individual  professionalsand  of  each  health  profession
           and the means to communicate'these to the system; and 5) a method
           whereby hospitals can receive assistance in developing programs for
           staff based in patient care needs.

           These understandings of the current  system  and  the  subsequent  develop-
           ment of a more meaningful system will  result  from  the  following  three
           related activities:




           MISSOURI Regional Medir_lal Program'           -2-                  RM 00009  7/70.2


                                                            ctivit
                1.   A Continuing Education Cooperative A          y proposes the
                     establishment of an inventory of continuing education
                     activities in the six subregions of Missouri.  An outgrowth
                     of this activity would be a clearing-house function to make
                     available information on continuing education programs to
                     all health professionals of the Region.  An Advisory
                     Committee whose tiembers will be drawn from the producers
                     and consumers of continuing education activities in
                     Missouri will review the inventory and appraisal data and
                     recomend educational programs which should be initiated.
                     Staffing for this part will consist of two half-time co-
                     directors (salaries paid by the University of Missouri)
                     and a secretary.
                II.  The Teacher-Consultant  Activity  is  a  cadre  of  various  health
                     professionals who will establish linkages with the various
                     health professionals of the Region and between the health
                     professionals and the Advisory Committee on Continuing
                     Education. They  will  also  serve  as  liaison  with  the  organi-
                     zations and institutions on the Advisory Committee and
                     provide  advice  to  those  hospitals,  clinics  and  organizations
                     who wish to initiate and develop continuing education
                     activities.  Through  these  linkages  the  needs  of  the  indivi-
                     dual members of given health professions at specific
                     locations will be coordinated.
                     The proposers envision several    full-time physicians, educa-
                     tionalists, nurses, allied health professionals and
                     secretarial personnel in this component.
               III.  The Local Educational Coordinato               would place a
                     physician-coordinator in each of five subregions to assist
                     health care institutions and health professions in the
                     institutions to  develop  and  initiate  a  program  of  continuing
                     education.  The sixth subregion will be served by the
                     central office.
                     A coordinator will be placed in one of the subregions the
                     first year with additional ones to be added to the other
                     subregions during the subsequent years.
            All components will have available to them the facilities of the Medical
            Center and University and the benefit of contacts the non-campus staff of
            the University has made.  Hopefully, other participating agencies will
            volunteer additional resources.
            The control of the project is shared with the Missouri RMP, the Advisory
            Committee on Continuing Education and the Dean of the School of Medicine.






          MISSOURI Regional Medical Program          -3-              RM 00009  7/70.2


          Evaluation efforts will consider documentation of the time involvement
          of individual professionals, anecdotal reports of project personnel,
          surveys, information transfer and effect on patient care.

          The five-year $1,534,919 request consists primarily of personnel
          costs ($1,282,438).



          Second Year:  $179,345                     Third Year:  $234,260

          Fourth Year:  $485,531                     Fifth Year:  $526,187














                                                            DRMP/GRB/5/19/70






                                                            A PRIVILEGED COMMUNIC&TION


                                                              Missouri RMP 00009  7/70.2


          STAFF OBSERVATIONS

          The following is a summary of the past review actions and comments  of
          t!le Continuing Education - Coordination Project.

          July 30-31, 1969 Review Committee

          Core - Continuing Education

          Critique: The Review Committee and Continuing Education  and  Training
          Panel both agreed that this core activity speaks well to  coordination
          of continuing education activities but beyond the philosophical tenets,
          the proposal gives little indication of the activities which are going
          to take place.  Personnel costs, which constitute the largest budget
          item, are not justified by job descriptions or functions.
          Other than one general paragraph thereis little or no indication of the
          relation of this project to existing projects in continuing education,
          particularly Project #33, Continuing Education for the Health Professions.
          No evidence exists, in the form of letters, surveys or otherwise to
          indicate that the practicing physician, community hospitals or voluntary
          health agencies have been involved in planning this project, or  would
          support or utilize its services.
          In view of the vagueness and the unanswered questions, the Review
          Committee defers a recommendation until after the site visit  findings
          are available.

          Recommendation:  To include the application with the material to be
                           reviewed by the site visit team and defer a recom-
          mendation until the November 1969 Committee meeting when the site
          visit report is available.
          August 26-27, 1969 - Council recommended:  Deferral for further consideration
                                during the upcoming site visit.

          Site Visitors Comments, October 7-10, 1969.

          Core Continuing Education
               Spokesmen:  Dr. William Mayer, Mr. Gail Bank, Mr. John Mowrer, Mr.
                            Carl Marienfield, Dr. Vernon Wilson
          Dr. William Mayer was able to briefly describe his proposal,  and  the
          visitors discussed the proposal at greater length with Dr. Vernon Wilson,
          Mt. Carl Marienfield, and the proposed project  staff.  Unfortunately,
          Dr. Mayer was not present during the "feedback session" on  the  final
          day of the site visit to hear the site visitors' perceptions and
          recommendations.





         STAFF OBSERVATIONS                       -2-



         This is an extensive three-level operation designed to  bring  about
         coordination of continuing education activities within  the  region.
         The first level of activity, and the first priority, is  the  estab-
         lishment of a state-wide advisory council to involve institutions
         and agencies concerned with continuing education.  This framework
         would provide a headquarters for the University of  Missouri  Medical
         Center continuing education programs.

         The second level of activity is the provision of   teacher-consultant
         teams to identify the personal-professional needs of  individual  pro-
         fessionals and professional groups. The manner in  which  these  teams
         would accomplish this objective was not clearly defined.

         The third level of activity is the local education  coordinator  who
         serves as 'extension agent" in the communities.  Considerable difference
         of opinion was noted among the Missouri RMP, the  Extension  Division,
         the Medical Center representatives, and Dr. Vernon Wilson as  to  what
         the role and qualifications of this key person would  be.  There  was
         considerabledifferenceof opinion among the groups  concerned  as  to
         whether this individual should be a physician or should be  more  ofa
         sociologist or educator, whether he should live in the local community
         or be there on a part-time basis, whether he should work as a DME  in
         a local hospital or be based in other community resources.

         Impressions:  The visitors,likt the Continuing Education Panel, had major
         reservations about this proposal.  It seemed, primarily, to be organiza-
         tionally oriented to furthering the continuing education effort of the
         University of Missouri Medical Center. There appeared to  be  no  clear
         mechanism for feeding the educational benefits of RMP  activities  into
         this RMP "Core" proposal.  The proposal tended to be isolated from the
         other activities of the Missouri RMP, rather than central to and  in  a
         position to coordinate these activities as a "Core"  effort  should.

         The team had the highestregard for the leadership of Dr.  Mayer,  but
         was much less certain about the capabilities of the project  staff  on
         whom success of the project depended. In view of  the  differences  of
         opinion among the people concerned about the qualifications for the staff,
         the lack of philosophical agreement, the vagueness about the methods of
         identifying educational needs, the lack of systematic  evaluation,  and
         in view of the isolation of this project from the very activities which
         it should,be coordinating, the site visit team recommended  that  the
         proposal be returned for revision.  The site visitors noted  that  this
         recommendation coincided with the unanimous opinion of  the  Continuing
         Education Panel.


         November 5-6, 1969 Review Committee

         Project #47 - Core - Continuing Education.

         Critique:  The site visitors were directed by the August  1969  Council
                   to review this project during the  October  site  visit.  The








         STAFF OBSERVATIONS                         -3-



         site visitors found that although this continuing education activity
         would be funded as a part of the Missouri RMP core, it appeared
         organizationally oriented to furthering the continuing education  effort
         of the University of Missouri Medical Center.  Interviews with several
         other project directors indicated that the proposal seemed to be  iso-
         lated from other Missouri RMP activities and that a mechanism for  feed-
         ing the educational benefits from community-based activities into  the
         central core resource was lacking. These findings confirmed  the  under-
         standing the Continuing Education and Training Panel had about  the
         project. Although the Dean of the Medical School was able  to  respond
         only briefly to the site visitors about this proposal, the  visitors
         did hear from thoseconcerned with the direct operations of the  core
         component.

         The visitors were unable to obtain samples of kinds of data which
         would be used to identify educational needs.  There were varying opinions
         among the Missouri RNP, the Extension Division of the University,  the
         Medical Center representatives and the Vice President for  Academic
         Affairs, Dr. Vernon Wilson, as to whether the extension agent  described
         in the third level of activity should be a physician, a sociologist or an
         educator; whether he should live in the local community or  commute;
         whether he should be a DME in a local hospital or be based in  other
         community resources,  The major criticism of this proposal, however,
         was that its focus is on the development of an organization  rather
         than on the improvement of patient care. The site  visitors  recommended
         that the Region revise the proposal and develop a vigorous  continuing
         education program as part of RMP and directed to RMP needs.

         The Review Committee, however, believed that such a continuing  educa-
         tion resource was needed in the Missouri RN:P program and should be en-
         couraged, despite the substantial university influence.  The site
         visitors' recommendation was modifipd.to approval with no RMP funds to
         be included in the award for this component (the Region may rebudget
         its previously awarded funds) and with significant feedback to  the
         Region detailing the site visitors' concerns. The reviewers  hoped  that
         the Region would consider these concerns when requesting funds for  this
         activity again.

         Recommendation:  Approval, no new RMP funds recommended.

         December 16-17, 1969 - Council recommended:  Nonapproval with revision required.











                                                                       DRMP/GRB-5/19/70








                                                            A  Privileged  Communication



                             S@RY OF REVIEW AND CONCLUSION OF
                                  JUNE 1970 REVIEW COMMITTEE


                             MISSOURI REGIONAL MEDICAL PROGRAM
                                       RM 00009  7/70.2

                      FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


             Project #63 - Continuing Education - Coordination     ect
             Critique: Committee reviewed the background of this  project  which  had
                       been reviewed by Committee, deferred for a site visit and
             returned for revision by Council.  Previous criticisms related to the
             following points: (1) the focus was on development  of  an  organization
             rather that on the improvement of patient care; (2)  reviewers,  including
             site visitors, were unable to determine what kinds of data would  be  used
             to identify educational needs-, (3) there were varying opinions among
             university, RMP And project representatives about the role of  the  exten-
             gion agent; (4). a mechanism f or f eeding the educational benef its f rom other
             Missouri RMP activities, especially cominunity-based ones, into the continuing
             education core seemed lacking and (5) there was a lack of systematic evaluation.

             Committee reviewed the revised proposal in light of these  criticisms  and
             were not satisfied that the previous deficiencies had'been corrected.
             The project does not speak, except in passing, to the linkages  which  need
             to be built between the education function and other  agencies,  schools
             of allied health, and RMP projects which have already successful education
             activities.  Evaluation efforts still seem vague and a more detailed
             method of identifying needs than'appeared in the original  application  is
             @missing.  Reviewers were not satisfied that the elaborate three-step organ-
              zation, unchanged since the original application, would  improve  continu-
             ing education efforts in the Missouri RMP.

             While the reviewers were impressed with the quality of leadership the
             Dean of the Medical School, as co-director5 would bring to the project,
             they were uncertain that he would be able to devote enough of  his  time
             to the project to assure the quality of direction requisite for  a  project
             of this magnitude. There was agreement that the Missouri  RMP  needs  to
             identify educational needs and coordinate their continuing  education  pro-
             grams, but it was pointed out that this type of activity  is  ordinarily
             a function of core and performed at much less expense to the Region than an
             average cost of $400 000 per 'eat. While some  reviewers  believed  that
                                          y
             the vroi6ct should be approved (at a much lower level.) in order to  permit
             the Region to initiate the clearinghouse and catalyst function, the
             majority were of the opinion that the project did not merit any support
             and should be disapproved.






             Missouri RMP                      2                  RM 00009  7/70.2


             R6cpm6ndation:  Non-Approval  I (no MT funding recommended.

             Th&re was one dissenting vote.

             Note:  The comments requested from an outside reviewer were not received
                    until after the Review Committee meeting.  His review essentially
             corroborated that of Committee.  He, too, believed that the ap lication
                                                                          p
             had not responded to the criticisms of the site visitors, Committee and
             Council, and that the implicit principles upon which the proposal was
             based were educationally unacceptable.

             While he could find some value in the local Educational Coordinator
             function, he too believed that the overall project should be disapproved.





























                                                           RMPS/GRB  7/14/70



















            0                                                              0                                                              0











                                 REGIONAL MEDICAL PROGRAMS SERVICE
                       SUMMARY OF AN OPERATIONAL SUPPLEMENTAL CRANT APPLICATION
                                      (A Privileged Communication)



               MOUNTAIN STATES REGIONAL MEDICAL PROGRAM               RM 00032 7/70.1
               Western Interstate Commission                          June  1970 Review Committee
                 for Higher Education
               University East Campus, 30th Street
               Boulder, Colorado  80302

               PROGRAM COORDINATOR:  Kevin P. Bunnell, Ed. D.


               Requested
               Program
               Period            Ist Year        2nd Year        3rd Year       Total

               Direct Costs      $184,976        $191,117        $197,804         $573,897
               Indirect Costs       21,950*        27,268*         28,348*          77,566*


               TOTALS            $206,926        $218,385        $226,152         $651,463

               HISTORY:  The initial planning grant for this Region became effective
                         in November 1966 and provided for the organization and
               staffing of the core program, a four-state  study  of  resources  necessary
               for an operational program, and the establishment  of  four  state  offices,
               the Regional Director's Office in Boise, and  the  Coordinator's  Office  in
               Boulder.  The operational phase began in March 1968, and the current
               annual level of support is $1,541,557, which supports Core Administration,
               four State Offices, the Regional Director's Office and the Program
               Coordinator's (Executive Director) Office at  the  WICHE  Headquarters)  and
               seven on-going operational projects, as follows:

               PROJECT                 TITLE                      FUNDING  LEVEL  (d.c.o.)

                  1                 Core Administration                $943,587

                  2                 Coronary Care Training
                                     Missoula                           134,349


                  3                 Diagnostic, Treatment, and
                                    Educational Program for Cancer      207,172

                  5                 Continuing Education - Montana      104,956


                 Does not include Idaho Heart Association Indirect Costs.








                                                            -2-       RM 00032  7/70.1
              140@TAIN STATES REGIO?\'A-L IEDICAL  PROGRAM

                                   Tumor Registry                      $134,472
                @6
                -7                 Continuing    Education  Nevada     78,243
                                   Inhalation Therapy                  79,659

                  9                Intensive Cardiac Care
                                     Nevada                            62,195

                10                 Consulting Team - Continuing
                                     Education - Rural Nevada          40,000
                11                 Continuing Education - Idaho        38   196
              TOTAL                                                  $1,822,829
              PRESENT APPLICATION:  This application requests funding for two
                                     projects to extend on-going successful activities
              into new geographic areas.
                                  ICU  Trainine  in  South             This              sted
              Pro'ect #12                                west Idaho.
                             program is designed to provide nurse and              Filrst Yyear
              physician training  for  acute  coronary  and  general  intensive    $107,469
              care in Southwest Idaho and Eastern Oregon.  This is a rela-
              tively dense population  area  of  the  Mountain  States  Region.
              The,.program represents the  combined  efforts  of  three  communities
              (Boise, Caldwell and Nampa), the Idaho Heart Association and
              the-WICHE Rie.
              The program is  patterned along similar lines of the Intensive
              Coronary Care  Training Program  in  Missoula,  Montana  which  serves
              communities of Montana, Northern Idaho and Wyoming.  This was
              the-.basis of the original  operational  grant  to  the  Mountain
              States RW .  It has demonstrated the feasibility of a regional
              approach to training  personnel  to  staff  coronary  care  facilities
              in-small hospitals,  and  has  trained  107  physicians  and  148
              nurses since  May  1968,
              This-proposal is also in line with the plan to develop subregional
              centers of continuing educat@on through cooperative efforts of
              local health professionals, facilities and colleges.  A nucleus
              of this plan is already present in seven locations in Idaho under
              the MSIRW program.
              The  training center for which support is requested is comprised of
              four  core hospitals which have  agreed  to  provide  classroom  space








             MOUNTAIN STATES REGIONAL MEDICAL PROGRAM  -3-       RM 00032  7/70.1


             and clinical facilities. All four hospitals  have  established
             coronary care facilities and have experience in coronary  care
             inservice training.  They are:  St. Alphonsus and St. Lukes
             Hospitals, Boise, Mercy Hospital, Nampa and Carwell Memorial
             Hospital in Carwell.

             Contributions by the four core hospitals and the Idaho Heart
             Association to conduct the initial courses for nurses have
             totaled $12,972; clerical assistance, office space and  teaching
             time by nursing preceptors and physicians was donated.

             The staff of any hospital in the Region and eastern Oregon  is
             eligible to participate in this training program providing  certain
             conditions are met. They must provide usable space and  a  workable
             plan for installing an intensive care facility that is well
             integrated with other hospital services. They must agree  to  use
             the standardized data collection methods provided by the  program
             and make these data available for study. A  specific  registered
             nurse to work with the RNP consultants must be designated, and
             cooperating hospitals must participate in the postgraduate train  ng
             activities of the program.  Approximately 96 to 100 nurses can be
             trained in the first year; priority will be given to nurses  from
             Southwest Idaho and Eastern Oregon, who will be working in a  CCU
             general intensive care unit or a combined unit. Initially,  courses
             will be limited to 24 trainees.

             Physicians have requested training programs designed especially  for
             the small town practitioner. Three-day symposia for up  to  24
             physicians will be conducted three times a year with faculty  of
             physicians and nurses staffing the training center, a  physiologist,
             pathologist and a consultant cardiologist. One two-day session  will
             be held each year offering information beyond the basic  coronary
             care that physicians need to keep up to date.

             The WICHE organization will enter into an agreement of  affiliation
             with the Idaho Heart Association, which will serve as the coordinating
             and fiscal agent for the project.

             The Executive Director of the Idaho Heart Association will  serve
             as Project Director, without salary.  The  physician faculty will
             be employed part-time.

             The basic course curriculum will be evaluated in terms of the course
             objectives. The individual trainee entering and  completing  the










                                                                          RM 00032 7/70.1
              MOUNTAIN STATES REGIONAL MEDICAL PROGRAM

              course will evaluate her own progress through these objectives.  After
              the.student has r eturned  to  her/his  own  clinical  environment   and
              ha@.-,had opportunity  to  implement  training,  further  evaluation  of
              th@,@basic  curriculum  can  be  made  through  feedback.  A  physician
              and 'nurse  consultant  from  other  coronary  care  training   programs
              will be  invited  to  assist  with  an  objective  evaluation,  i.e.,
              Mis.soula, Montana, and Seattle, Washington.
              The general level of coronary care will be assessed through changes
              in mortality rates utilizi  ng  data  collected  throughout  the   four
              stat es.  Several  indices  will  reflect  the  degree  of  interest  and
              cooperation in  the  Regional  Medical  Community,  such  as  the  number
              of -applications for training, number of facilities that have
              bec ome  available  to  patients,  evidence  of  sharing  educational
              talents, skills and tools, and opinion data from participants,
              e-,np.,@ipyers and associated staff.
              Sec@o,rid Year:  $105,894             Third Year:  $110,377
              Project #13 - A Program for Continuing Nursing Education                   sted
                                 min .  This is a supplemental proposal for         First Year
              continuing education of the Mountain States RNP, and is a              $77,507
              third phase of a course of action to develop a cooperative
              continuing education program for nursing for the four-state
              regi.on.  It will provide a program of continuing education
              for.,--n-ursing personnel in Wyoming in cooperation with similar
              programs in Idaho', Montana and Nevada.
              The.Iprogram  will:  1)  develop  a  sustaining  "system"  of   continuing
              education;  2)  develop  a  sound  educational  approach  which  involves
              the learners  and  provides  continuity  and  coordination  in   pro-
              -gra mming; 3) train key  people  in  the  process  of  adult  education;
              4) develop part of the  program  at  "the  home  base  of  the  learner";
              andi@) develop a continuing education program for nurses in
              anticipation that continuing education requirements may become
              a,,necessary prerequisite for annual li.censure.
              The-,,School of Nursing in the College of Health Sciences at the
              University  of  Wyoming  will  provide  the  administrative  focus  for
              the      ect, and will  work  closely  with  the  Division  of  Adult
                  -proj
              Education and Community Services.      A  Project  Coordinator,   one
              nursing  teacher  and  an  administrative  secretary  will  be  employed
              when-the project is funded.  Six months later a second nursing









               MOUNTAIN STATES REGIONAL MEDICAL PROGRAM  -5-         RM 00032  7/70.1


               teacher and a clerk-typist will be added. The project  staff  will  be
               an integral part of the University of Wyoming School of Nursing.

               The Region has developed a plan which will divide Wyoming  into  four
               zones. These are based upon geographic  factors  and  representative
               of established patterns of relationships and cooperation between
               health facilities.

               The educational activities will involve workshops, clinical con-
               ferences, and consultative services. The project is  ready  to  become
               operational immediately upon approval and funding.

               A feasibility study was initiated during the planning phase which
               organized four study groups of nursing personnel throughout the
               State to study the continuing education data from survey quest onna res.
               As an outcome, a statewide Continuing Education  Advisory  Committee
               for Nursing was appointed to serve for the duration of  the  project
               and will continue in a permanent capacity to the University of
               Wyoming School of Nursing. A Task Force selected  from  this  Advisory
               Committee has been responsible for the development of  this  applica-
               tion.

               An independent study laboratory grant application has  been  approved
               under another program -but not yet funded for the University of
               Wyoming School of Nursing. All of the seven  community  colleges  in
               Wyoming support the project and offer full cooperation, making
               available faculty, and audiovisual materials and physical facilities.
               Other agencies such as the Nurses Association, the Wyoming League for
               Nursing, the Wyoming Heart Association, etc., have also documents
               their cooperation and commitment.

               The evaluation of the project will determine the  effectiveness  and
               efficiency of curriculum content, instruction and planned educational
               experiences and will involve mechanisms such as:  descriptive progress,
               reports@, questionnaires and conferences with participants in  health
               care facility administrators.  Reports will be prepared semi-annually,
               including appropriate project and curriculum changes.

               Second Year:  $85,223                       Third Year:  87,427





                                                           DRNP/GRB
                                                           5/22/70




                                                                 A Priviieged  uomaitin3.caLion.







                                     SU@,R,iARY OF REVIEW AIID CONCLUSION OF
                                         JUNE 1970 REVIEW COIDLITTEE

                                                          'DICAL PROGRA!4 (I)ICIi,)
                             MOIJI.qTAII,l SFATES REGIOI@AL Idy,@
                                                MA 00032 7/70.1

                              FOR COiNSIDERA'rION BY JULY 1970 ADVISOIIY COUNCIL


             General.:  The  committee  approved  the  present  application   requesting   $184,976
                        for  two  new  operational  projects  to  extend  ongoing  activities  into
                        .new geographical areas.

             Project i@12 - CCU-ICU Traini.@IZ_in Southwest Idaho
             Lrit:L@ie:  The reviewers endorsed the findings and recommendation of the
                         Ad Hoc Cardiovascular.Study Panel which found its objectives
             clear and  obtainable  ,iithin  the  proposer]  time  limit.  The  reviewers  believed
             that  it  would  be  helpful  if  "student  objectives"  for  educational  training
             program could be included.
             The  procedures  are  adequately  described  and  the  approach  is  realistic  and
             workable. The  project  should  enhance  inter  and  i.ntr@--comriiunity  cooperation,
             knowledge and respect.     The Committee noted. hear provision is made for
             consultation with outside sources.

             ilie budget requested was believed  to  be  reasonable,  but  i,t,w@is  unclear  as
             to whether $3.00 tuition fee is realistic.      Other areas ai-e:charg-'Xi-tg between
             $300 and $350 for a 7-week program.
             Although details  about  the  mechanism  for  evaluation  are  not  included  in  the'
             application, evaluation seems to have been considered in all areas pertaining
             to the impact of the program upon the individual riu@-ses ind physicians, is
             well is the impact upon the community and region.
             Other resources of  support  are  being  utilized  from  8  prior  pilot  project  and
             the local Heart Association.      Tuition fees ai:c,. also expected  to  assist  in
             defraying costs.
             Phasin  out would seem to evolve naturally but the reviewers raised the
                    9
             question   of   cost-sharing.
             The  project  overall   shows excellent coordination within the region, is tecl-ini-
             cally sound and capably dir'ected.

             Recoi-ii@-r@endation:   ApprovalI

                          First Year                  Second Year             Third Year
                          $107,469                    $105,894                $13.0,377




               MOUNFAIN S'EATES IU/IP kV@'IULiL)                       -4-                      &WI vvv@@ I i I


               Project i'@13                                  II           -rdtic6ti.oli
                  t@i q i@e :There wa-@ consensus tliit this program is well organized and
                             comprehensively planned.   It is obviously supported by all
               professionals in th@- area which speaks highly of the involvement of  the
               three baccalaureate school,,; of nursing, as well as the seven community
               colleges that have been involved.
               The program will emphasize "training the trainer" and                  using the "home base"
               of the learfier as the teaching laboratory.   The educational activitie                   s are
               described but the behavioral objectives, content and length of courses will
               apparently be developed after the personnel are hired.
               The   reviewers   noted   that    the    applica tion shows a weakness in that with all
               of the coordinated planning and preparation for this program, they have not
               spelled-out in any detail the curriculum that is proposed.   For instance,
               will there be clinical experience to enrich the training? This is not to
               imply that there is doubt that the trainers will be well prepared but the
               Review Committee felt it would be advisable to have the region submit more
               details about the planned curriculum for staff review.
               The   Review   Committee.   noted   that   the   university   has   agreed    to    assimilate
               this project, subject to the availability of funds and other resources at
               the end of the third year.
               Recoin@@iendation:    Approval I - Conditional upon submission of curricula as
                                      they are developed for review by Continuing Education Branch.


                              First Year                         Second Year                   Third     Year
                              $77,507                            $85,223                        $87,427


                                       SUIIil@IARY OF l@COij@,ENDATIONS
               r@j,@C               01-Year           02-Year             03..Yeir                 TOTAL
               #19                  $107,469          $105,894           $110,377                  $323,-iliO
               #13                   $ 77,507         $ 85,223           $ 87,li.27                  @250,157

                        Total       $1.84,976         $1@91.,117         $197,804                    $573,897



                                                                                     RMI'S/GRB/7/13/70


















            0                                                              0                                                              0













                                REGIONAL MEDICAL PROGRAMS SERVICE
                    s     Y OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                  (A  Privileged   Communication)


          NEW MEXICO Regional Medical Program                   RM 00034  7/70.1
          The University of New Mexico                          June      1970  Review
          Albuquerque, New Mexico    87106                      Committee
          ,Program Coordinator:  Reginald R. Fitz

          Rttauested
          Prmram
          Period:            lst Year          2nd Year           3rd Year          Total
          Direct Costs      $180,895            $174,324           $112,834        $468,053
          Indirect Costs      38,614              42,630             26,633         107,877

          TOTAL             $219,509            $216,954           $139,467        $575,930

          HISTORY-. The initial planning  grant  in  the amount of $449,736  was  awarded
                    for the period of  October  1,  1966 to November 30, 1967.  Seven-
          month planning funds in the amount of $108,048 were  made  for  the  second-
          year planning continuation (December 1,1967 to June 30, 1968).  This
          phasing was due to the Region*s submission of its first operational request,
          which was disapproved by the National Advisory Council in May 1967.
          The application comprised of 7 projects was  revised  and  resubmitted  for
          consideration by the May 1968 Council with  a  resultant  affirmative  action.
          The Region's first operational award in the direct  cost  amount  of  $965,305
          was made, effective July 1, 1968, to  support  seven  operational  projects,
          Core staff, and one project (#8) from earmarked funds,  and  for  the  last
          two months of the grant year, (from anticipated unexpended funds) implemented
          a Cardiopulmonary Laboratory in Seats Fe (#10).
          Another supplement requested funds for Project #11,  to  establish  a  model
          rural clinic.  This project was later funded by NCHSR&D-by contract.
          A project to screen New Mexico School Children for Heart Sounds and Murmurs
          (#12) was reviewed at the February/March cycle.  The reviewers were in
          agreement that the proposal was a significant one for the region, but
          identified several areas in need  of  clarification  and  re-structuring.  The
          recommendation was unanimous for a return  for  revision  and  resubmissioa.
          This will probably be forthcoming for the next cycle.




            NEW MEXICO Regional Medical Program      -2-         RM 00034 7/70.1

            Continuing support for the second operational year was made in the direct
            cost amount of $1,252,911 for a 14-month period.  The Region is presently
            funded at an annual level of $1,053,768.
            PRESENT APPLICATION: This is a three-part application requesting funds to
                                 support three new programs.  One of these (Project#14)
            was presented to the staff in March as a request for rebudgeting of funds
            to support a pilot phase of a monitoring program for decentralized coronary
            care units.  Because the proposal involved many technical and clinical com-
            plexities, and indeed presented a new dimension to the New M&xico Program,
            it was the consensus of the staff that approval of any rebudgeting to imple-
            ment this pilot study before submission to the Review Committee and Council,
            was inappropriate.
            The other two operational projects making up this three-part supplement are
            (#13) Leukemia-Lymphoma Program and (#15) Streptococcal Throat Culture Pro-
            gram.  These programs represent new operational efforts.
            Prolect #13 - Leukemia-Lymphoma Pr_p_gram.  This proposal will initiate  First Year
                         a LeuKemia-Lymphoma Center which will be organized to      Requested
            provide-education, drugs and consultation to the referring physician     $73,275
            for patients with hematologic malignancies.  The project will be
            located at the Bernalillo Medical Center, a fully accredited general
            hospital and one of two major teaching hospitals of the University of New
            Mezico School of Medicine.  A $6 million addition now under construction
            will be completed in 1970 to provide expanded laboratory and radiology
            facilities, a new emergency suite, new out-patient facilities consisting  of
            102 rooms, a new operating room suite and intensive care facilities.  This
            hospital also contracts with the USPHS for care of Indian patients from the
            Navajo, Apache and Pueblo Reservations.  The majority of patients come from
            the more than 300,000 residents of the county.
            The Project Director is already identified.  In collaboration with a
            health educator, who will probably need to be bilingual, he will develop
            an educational program to communicate to thelbysicians throughout the
            State the availability of such collaborative care  and  investigation  of
            patients with leukemia or lymphoma.  This program will be designed for
            medical students, house staff and physicians.  An in-patient therapy unit)
            including a patient isolation system will be established, in collaboration
            with the departments of Pathology, Radiology,, Pediatrics,  Microbiology,
            Epidemiology and Community Medicine, and the services of  the  Infectious
            Disease Laboratory and Blood Bank.
            Clinical records on all patients w@th leukemia and lymphoma will be main-
            tained for follow-up and epidemiologic studies in collaboration with the
            existing NM/RMP Tumor Registry.
            The M.D. Anderson Hospital and Tumor Institute in Houston and the South-
            west Cancer Chemotherapy Study Group will participate through other sources
            of funds to develop immunotherapeutic approaches to acute leukemia, first
            in animals and later in humans, in collaboration with the Immunology Program,




            NEW MEXICO Regional Medical Program  -3-             RM 00034 7/70.1

            A full-time technician, a nurse social worker secretary, a full-time
            health educator will be required and a Co-Director will be employed at
            15% of the time.

            Second Year:  $67,355
                                                                                    First Year
            Project.#14 - Monitoring of Decentralized Coronary Care Unit. The            sted
            proposal here is similar to a project underway in t e Oklahoma REP       $85,520
            since May 1969.  It will build on experience of the Coronary Care
            Nursing Training project of the NMIRMP and will initiate pilot pro-
            jects involving  satellite hospitals in Grants, Gallup, Espanola and
            Albuqqerque.
            The program will initiate training for physicians and nurses for monitoring
            and supervising personnel in the central monitoring  unit.  The  training
            for nursing personnel at the remote unit will include training in cardio-
            pulmonary resuscitation, intravenous medication (where applicable), pro-
            cedures for defibrillation, clinical recognition of  emergencies,  etc.  The
            course, approximately 40 hours, will include on-the-job training  in  the
            central monitoring unit as well as the remote unit.  These  activities  have
            already begun at the Osteopathic Hospital in Albuquerque, i4 anticipation
            of being tied into the Bernalillo Medical Center, Albuquerque, in  the  near
            future.
            The training of physicians in the remote units will conform to  the  outline
            of the course designed to acquaint physicians with the management of patients
            with acute myocardial infarction, particularly in the areas  of  prophylaxis
            and treatment of cardiac arrythmias.
            Although written documentation is not a part of this application the
            Espanola Hospital has indicated its willingness to participate.
            The@@patient will be monitored on a continuous basis at a  Central  Monitoring
            Unit <CMU) in his geographical area by means of an electrocardiogram(ECG" to be
            transmitted by direct telephone wire from the remote station.  A parallel
            line will provide voice communication without dialing.
            The ECG monitoring will be done by skilled personnel at the CMU.  Nursing
            personnel at the remote station will be trained in procedures  to  be  applied
            when emergencies arise.
            The CMU and its remote station will function as  an  integrated  coronary
            care unit, Training programs and operational  procedures  for  physicians  and
            nurses will be developed.  Short courses for physicians aad nurses have
            been designed to fill the immediate need for specialized personnel needed
            to staff newly formed units.
            The electrocardiographic signal of the patient is amplified  at  his  bedside,
            and is transmitted over the telephone line as a  frequency  modulated  signal.
            At the ddmtral unit the signa@ is de-modulated, the electrocardiogram recovered.




           NEW MEXICO Regional Medical Program   -4-       RM 00034 7/70.1

           Voice contact can be established at anytime, including alarm  situations,
           without inteiruping ECG transmission. Two telephone lines  will  be  pro-
           vided by the telephone company on a monthly lease basis. One line will  be
           conditioned for two-way voice communication; the other will be  specially
           conditioned for uninterrupted transmission of the ECG signal.
           Whenever possible existing monitoring equipment will be used at both  the
           CHU and remote station. This equipment, pius any  new  monitoring  equip-
           ment, will be tied into the ECG transmission system by engineering personnel.
           These field engineers will also be responsible for maintenance and install
           special circuitry for monitoring purposes.
           It is anticipated that the physician and nurse at the remote station must
           help plan for the use of their units as they become functional. They  will
           assist in preparing the initial training programs and other programs for the
           remote station and for CMU personnel. Each of the  CMUs,in  collaboration
           with remote units., will form a Coronary Care Unit Committee (CCU) to formulate
           policies and recommend procedures for-@operation of both units.  The  CCU
           Committee will be responsible for establishing refresher  and  continuing
           eduction programs for both physicians and nurses in its area.
           Second Year:  $772069                    Third Year:     $810069
           Proiect #15 - StreEtococcal Throat Culture Program. This program,       First Yr@,-'
                        developed in collaboration with the New Mexico Heart       Requestt---','.'
           Association, and the New Mexico Public Health Laboratory, will          $22,100
           establish a statewide facility for identification of group A strep-
           tococci on culture.  It will address the problem of extremely high
           incidence of acute rheumatic fever and rheumatic heart disease in the
           state. The program is designed to persuade physicians to  seek  identifi-
           cation of infections with subsequent appropriate treatment,  as  well  as
           educate the lay public to seek medical aid for possible streptococcal
           illnesses.
           The University of New Mexico School of Medicine will participate through the
           Chairman of the Rheumatic Fever Committee of the Heart  Association  (Dr.
           Mortimer), who is also Chairman of the Department of  Pediatrics  of  the
           New Mexico School of Medicine.
           The project will be limited the first year to the northern half of New Mexico,
           comprising a population of approximately 600,000.  The  second  year  the
           program will be extended to the remainder of the state.
           The physicians in the area to be served will be supplied with swabs,
           requisitions and mail-in envelopes.  A daily pickup will be established at
           a Post Office box in Albuquerque and pamphlets will be processed  by  the
           State Public Health Laboratory. Positive results will  be  telephoned  to
           the attending physician by laboratory personnel.  Positive  results  will
           be reported to the Public Health facility in each community as  well.  All
           results, positive and negative, will be returned to attending physicians






           NEW MEXICO Regional Medical Programs        -5-              RM 00034 7/70.1


           by mail.   Tae program will run seven days a  week  by  training  part-time
           help, such as a university studentsto staff  the  laboratory  on  weekends.
           With the 600,000 population to be served the first year, it is estimated
           that 40,000 cultures will be processed yearly, with a  25%  yield  group  A
           streptococci.  The second year should produce  70,000 cultures.

           The sheep b&6od agar plate-bacitracin disc technique will  be  used  at  an
           average cost of 50 cents per culture.

           Direct evaluation will not be possible without extensive preliminary
           study to determine exact rates of rheumatic  fever  within  the  state.  It
           is not believed necessary to do such a study since other communities have
           already documented the effectiveness of such programs.

           Second Year:  $29,900                       Third Year: $31,765





            ,iEW MEXICO RNP                 -6-                        RM 00034  7/70.1

                        OPERATIONAL STATUS - Based on a 14-month Award (D.C.)



            PROJECT
            NUMBER         TITLE                                        FUNDED   (02)
            1              Model Coronary Care Unit Training            $    170,379*
            2              Training Course in CCU Nursing                    65,305*

            3              Training in Laboratory Sciences in
                           Allied Health Professions                         98,569
            4              Stroke Program                                     178,877
            5              Emergency Health Services                         59,517

            6              Circuit-Riding Continuing  Education
                           C6urses                                           58,351
            7              Realth Information and Communication              38,662
            8              Pediatric Pulmonary Center (Lovelace)
                           (Earmarked Funds)                                 95,745
            9              Core Support                                       467,958

            10             Cardiopulmonary Evaluation Laboratory
                           St. Vincent's Hospital                            21,048*
            11             Rural-Urban Linkage for Improved             Funded by
                           Health Services                               NCH SR&D



                                                              TOTAL        $1,252,911



            *Includes a portion of unexpended balances  of  $104,791,  direct  costs.












                                                                         DRMP/' 5/78/70






                                                                           NEW @, ICO  PIFP
                                                                           RM 00034 7/70.1



              STAFF OBSERVATIOLIS


              Staff was concerned that the initial project proposal did not include
              certain relevant information.  Staff requested additional information,
              some of which has been forthcoming.

                    1.  The curricula  which we requested for physician and nurse train-
                        ing have been received andt@@.,e helpful.

                    2.  The "letters of support" from the participating institutions
                        have been received. Ilowever, they  do  not  all  indicate  a  firm
                        intention of the institution to participate in the project, or
                        even a good understanding of wliat,the project is about.

                    3.  The Addendum information  makes  reference  to  "initial  pilot  pro-
                        jects' involving  satellite  hospitals.  It  should  be  pointed  out
                        that the Division has  not  granted  approval  for  the  establish-
                        ment of such pilot projects; we are awaiting the action of Council
                        on the value of  this  monitoring  approach  before  considering  the
                        approval of such pilot activity.

                    4.  The addendum does not refer in depth to     the experience  with  a
                        similar kind of monitoring project in the Oklahoma Regional
                        Medical Program.  One anecdote is cited:  The drop in the
                        mortality rate from 31% to 6% in a small "remote" hospital
                        following the beginning of monitoring.  This 6% figure is sur-
                        prising, considering the fact  that  the  mortality  rate  in  most
                        sophisticated coronary care units is considerably higher.

                    50  It is still not clear what the I'Leart  Association  will  contribute
                        to this project.
                    6.  Lastly, although the Region was requested to do so, the addendum
                        contained no description of how  the  monitoring  might  work  in  an
                        actual clinical situation -- how cardiograms would be screened at
                        the central monitoring unit (will nurses sit watching the screen?),
                        how a nurse will be able to pick up a telephone handset to receive
                        instructions while at the same time resuscitating a patient, etc,
                        It is still hard for staff to visualize how this monitoring would
                        work in a typical alarm.situation.







                                                          A Privileged Communication




                                SUMMARY OF REVIEW AND CONCLUSION OF
                                    JUNE 1970 REVEIW CO.@IITTEE


                               NEW MEXICO REGIONAL MEDICAL PROGRAM
                                          RM 00034 7/70.1
                         FOR CONSIDERATION BY iny 1970 ADVISORY COU14CIL



            General: This three-project application requesting $180,895 in supplemental
                     funds received a recommendation of approval, with certain contin-
                     gencies, in the amount of $92,100.  In the case of l@13, the project
            will need to be revised, including a new budget.  Project #14 was presented
            to staff in March 1970 as a request for rebudgeting of funds to initiate a
            pilot phase of a monitoring program for decentralized coronary care units.
            Because the proposal involved many technical and clinical complexities, and
            indeed presented a new dimension to the NM/RMP, it was the consensus of  staff
            that approval of any rebbdgeting to implement this program before submission
            to the Review Committee and Council, was inappropriate.

            Project Y@13 - Leukemia-Lymph-oma Pro.@ram

            Eriti@e:  The reviewers found the project to be timely, well-planned, and
                       it will obviously serve a great need.  It will also be a valuable
                       research activity.  However, there is no indication that it is
            tied into a larger program dealing with all aspects of cancer, or indeed  that
            the Region has planned for the broader implications of a comprehensive  cancer
            program.  This is by and large a fragmented approach and the Region may be
            ignoring the overall necessity for planning a regionalized cancer program.

            The failure to identify therapeutic backup is another deficiency in the
            application, as well as a clear justification for the amount to be budgeted
            for drugs, return visits to laboratories, etc.  This was questioned as to
            whether this is legitimate or permissible.

            There is no evidence that this project is tied in with a clinical cancer
            activity, which one would surmise is ongoing in some area of the Medical
            School.  There is no radiotherapist or radiologist listed.

            The Region is requesting in-patient as well: as outpatient support largely
            to be able to follow the M. D. Anderson technique of sterile isolation.
            Since there is doubt in the profession that this approach will be  financially
            feasible, it would appear that this is not the area in which to experiment,
            or indeed, the point from which to start a canter program.

            The necessity for a full-time health educator was not clear from the  applica-
            tion.  The project generally needs clarification of its place in a more
            broadly-bbsed regional cancer program and further documentation as to its
            relationship to othe).- clinical cancer activities.

            R6commcndation:  NoLi-Appr'oval II - the revision should reflect: (1) this
                            'project's relationship to an overall regional cancer pro-
            gram; (2) statement of the proposed therapeutic and clinical backup;ard(3)
            - -i - -. -- r - . - @ -- - @, . r , - - . -. @, - - 1i,, . A - - i-





             NEW MEXICO RMP                          -2-               RM 00034 7/70.1


             Project itl4 - MonitorinR of Decentralized Coronary Care Units

                        The reviewers believed that the evaluation of this project must
                        be judged on the basis of the experience gained in a similar
             project in the Oklahoma RMP. (The reviewer for this project was also the
             reviewer for the Oklahoma one.@-,-'

             There was agreement that the budget includes equipment items which are
             probably unnecessary initially. The reduction in the  number  of  central
             monitoring units and remote stations to two areas until the demonstration
             proves to be feasible would be a more practical approach.  There  was  no
             reference to other training,programs which could possibly afford experience
             that would be valuable to this program.

             The reviewers recognized that this is a high risk population, with lots of
             retirees with a complicating factor of high altitudes.  The  approach  is
             reasonable in that it joins such facilities in the state  along  regional
             lines.

             Recommendation:  Approval I - at $70 000 the first'year, with the provis2'.o'n
                              that: (1) An evaluation of the Oklahoma project be made both
             at the source and one of the remote stations; (2) the first year's activities
             should be limited to no more than two satellite installations with a com-
             mensurate reduction in the budget to reflect a request for no more than $5,000
             for equipment. The second and third year's budgets are to be  limited  to
             $70,000 direct costs each year.


             Project Y@15  Stre tococcal Throat Culture ProRrarn

                        There were a number of deficiencies noted.  While  operational
                        procedures are adequately described, the technical  procedures
                        are not.


             Personnel described appear inadequate for operation on a seven-day week basis,
             and it would seem that an additional half-time technician would be necessary,
             as well as  c'lerical assistance to maintain records and notify physicians.
             Good records will be necessary to provide evaluation of this program.

             Miile the difficulty in estimating the actual effect of 'reducing rheumatic
             fever is recognized, methodology for evaluation ts not included.  There is
             no evidence of folloig-up of the cultures or indication of what will happen
             to these.  The technical procedures are not adequately described, nor are
             the limitations of the technique.-.  It is assumed this method will improve
             the effectiveness of detection of streptococcal pharyngitis and thereby reduce
             the incidence and recurrence of rheumatic fever.  Although two mechnisms are
             mentioned by which objectives may be obtained (physician education and parent
             and patient education), these are not adequately described. The  need  to
             expand the educational and information phases must be strengthened considerably.

             The reviewers also directed their attention to the relationship of this
             project to the State Department of.Realth and to the Indian Heilth Service,





               NE14 MEXICO RIIP                             -3-                    101 00034 7/70.1


               The region does not     report the means of contact with the Icidiaris and
               Spanisli-Araerican populations.. It would appear that at lea.,,t a Spanish
               speaking nurse would be required to elic@l-t the kind of information that
               will be needed.

               The  budget  seems  reasonable,  but  an  additional  ,@6,000  -  $7,000  should   be
               considered fo-r-additiotiil.staff unless cooperating agencies provide the
               staff suggested.     It would seem TI-).,7t-Ehe  support  of  the  New  Mexico  State
               Health Department is essential and available,

               Recom,-aendatioLi:  Approval I,- with two contingencies: (1) The Region should
                                   identify  the  relationship  of  this  project  to   the   Indian
               Health Service and the State Department of Ilealtli; (2) provide a statement
               of  the  means  of  communication  with  Indians  and   with   the   Spanish-American
               population; and (3) clarify how the region plans to provide the treatment
               necessary for follow-up of positive cases in the population who live in
               remote areas.





                                               SUMMARY OF RECOM14ENDATIONS



                                                  01-Year           02-Year              03-Y.ear
               #13 - Leukemia-Lymph6ma                    Non-Approval II -'rc.,@visi.on

               #14 - Monitoring of CCtls          $70,000          $70,000                $70,000

             '#15    Streptococcal Tnroat
                     Culture                       22.100          -L9 :-LQQ             3_L  765

                     TOTAL                        $92,100         $99,900                $101,765







                                                                        R@IPS/GRB/7/8/70



















            0                                                             0                                                              0











                               REGIONAL MEDICAL PROGRAMS SERVICE
                    SUMMARY OF A SUPPLEMENTAL OPERATIONAL GRANT APPLICATION
                                 (A Privileged Communication)


              NEW YORK METROPOLITAN REGIONAL MEDICAL PROGRAM    PY 00058 7/70.1
              Associated Medical School of Greater New York     June 1970 Review Committee
              2 East 103rd Street
              New York, New York  10029

              PROGRAM COORDINATOR:  I. Jay Brightman, M. D.

              Requested
              Program
              Period            lst Year       2nd Year       3rd Year       Total

              Direct Costs      $1,524,229     $1,494,983     $1,528,195      $4,547,407
              Indirect Costs       425,782        499,925        520,041      1,445,748


              TOTAL             $1,950,011     $1,994,008     $2,048,236      $5,993)155

              NOTE:  A Review and Funding History (R&FH) indicating Council  action for
                     this Region is attached.

              HISTORY: The National Advisory Council for Regional Medical Programs
                      approved in February 1967 the initial planning application
              submitted by the Associated Medical Schools of Greater New York.
              Included in this grant award was a total of $123,660 for a cancer  study
              by the Memorial Hospital for Cancer.

              In June 1968, the Region was awarded a non-competing continuation  grant
              application at a level of $1,041,617 ($783,716 of new funds - $257,901
              of carryover funds).  Included in this award as $79,660 of unexpended
              funds for a seven-month extension of the Memorial Hospital Study.  In
              addition, the Region was awarded from earmarked funds $206,870 Pediatric
              Pulmonary Disease Project at Babies   Hospital and $88,399 for a  Mobile
              Coronary Care Unif at St. Vincent's Hospital, a total award of $295,269.

              In November 1968, the Region was awarded a supplemental planning grant
              application of $76,100 for the Memorial Hospital Feasibility  Study.  In
              March 1969, Dr. Jay Brightman became the Region's Program Coordinator.

              In late August 1969, the Region submitted a continuation application
              requesting support for the Pulmonary Disease Program. This  applicat  on
              modified the program by including two supplementary parts, one from
              Albert Einstein Hospital and one from St. Vincent's Hospital.  The
              application was approved at the committed level for 02 year of  $201,660







               NEW YORK PM                      -2-         RM 00058 7/70.1


               with the recommendation that the 'broader approach be utilized for
               greater coordination among the  th ree institutions.
               In July 1969, the Council approved the Region's initial operational
               grant application. Although approved for  operational  status,  support
               of the Region was continued by a planning grant  award.  This  was
               due to the uncertainty of the level of the Fiscal Year 1970 appro-
               priation foi.- Regional Medical Program grants (ref. to R&FH).
               Council received in August 1969 the Region's grant application
               requesting support for eight operational projects and  renewal  of
               Core.  Council approved operational status for the Region as
               recommended by the July 1969 site visit team and,the RNP Review
               Committee and the initial operational award was made  in  February
               1970. The Operational Award of $1,864,141  (d.c.o.)  consisted  of
               $1,245,658 for Core and $618,483 for support of five projects.
               The amount for Core included $44,194 earmarked funds for planning
               with the New York Health and Hospital Corporation, and $141,010
               for Project #7 - A Study of Facilities and Services for R      ator
               Diseases and Disorders (ref. to R&FH).

               Council reviewed this Region's first operational supplemental
               application in December 1969; it approved three of the projects at
               a level of $325,746 (d.c.o.) and disapproved one project (ref. to
               R&FH).

               The March 1970 Council reviewed the Region's  second  supplemental
               operational application which included two projects.  They were
               projects #14 - 'RMP Coronary Care Training Center at New  York  Hospital
               and #15 - Pilot Neonatal Special Care Center at New York.University.
               College of Medicine. Council disapproved both  projects  and  requested
               their revision.

               PRESENT APPLICATION: This supplemental operational grant application
                                    is requesting $5,993,155 (d.c.o.) for three years'
               support of threeprojects, a Renal Disease Program, a Stroke Program
               and An Interlibrary Loan Training and Consultation Service Program.
               Project #16 - A Reqional Program for Kidney Disease for       Requested
                             Brooklyn and Staten Island.  This is the       First Year
               third end-stage Renal disease project submitted by the New   $1,033,411
               York Metropolitan Regional Medical Programs.  The first,
               submitted by the Mt. Sinai School of Mediciane and its
               affiliated Elmhurst Hospital of Queens, was disapproved









               NEW YORK RNP                      -3-              RM 00058  7/70.1



               by Council primarily because there appeared to be no overall
               Regional plan for Renal diseases. The  second,sponsored  by  the
               New York Hospital in conjunction with the St.  Luke's  Hospital
               and the Brooklyn-Cumberland Medical Hospital, was  approved  by
               the Council after a site visit. Council approved  a  first  year
               level of $181,300 for training and planning aspects. These projects
               are all considered by the Region to be components of a total master
               plan in Renal diseases that the Region expects to  have  completed
               within the next few months.

               This project is submitted by the Downstate Medical  Center,  Brooklyn,
               New York and is a collaborative effort by seven hospitals in Brooklyn
               and Staten Island coordinated by a Council made up  of  the  Directors
               of Nephrology from each hospital. This Council will  formulate  policy
               and continually evaluate on Igoing programs of Renal care at the
               seven institutions. All of the unit directors  hold  faculty  appoint-
               ments in the Department of Medicine of Downstate  Medical  Center.
               The seven participating institutions are: 1)  Downstate  Medical
               Center; 2) Brookdale Hospital; 3) Coney Island Hospital; 4) Jewish
               Hospital of Brooklyn; 5) Prospect Heights Division of  Long  Island
               College Hospital; 6) Maimonides Medical Center; and  7)  Staten
               Island Hospital.

               This program proposes to institute the following activities:

                    1.  Establish a central "routing office" that  can  locate
                        available b@ds in the  participating  institutions  or
                        patients needing maintenance hemodialysis.

                    2.  Increase homedialysis facilities  for  selected  patients
                        who appear socially and emotionally suited for  this  type
                        of care: (a) as a  permanent  treatment  modality  or  b)
                        while awaiting a suitable cadaveric donor.

                    3.  Establish new collaborative relationships  through  the
                        mechanism of the Project Council.

                    4.  New transplant facilities will be developed  at  Downstate
                        (four beds) for selected patients, properly  worked-up  on
                        an out-patient basis, which includes  tissue  typing.  All
                        data will be recorded on standardized flow  sheets  developed
                        by the transplantation  registry.  Additional  transplant
                        units will be developed in participating institutions.

                    5.  Teaching and training activities will be integral components
                        of each of the seven programs.  Extension of the services of
                        special care units will be provided by  arrangements  between









                                                                Rm 00058 7/70.1
              NEW YORK                          -4-


              the collaborating units and voluntary  hospitals.  A  special  com7
              munity education program will be devised to increase lay aware-
              ness of the signs of kidney disease and the  need  to  encourage
              organ donations.  Each institution will stress its special
              training skill as follows:
                   A. Brookdale Hospital Center - A tw@  hour  per  week  lecture
              series of approximately 20 weeks duration will  be  given  twice
              yearly for community physicians.  The lectures will include basic
              materials as well as practical aspects in  the  diagnosis  and  treat-
              ment of Renal disease.  There will also be workshops which will
              offer first hand practical experience in  peritoneal  and  hemo-
              dialysis. A participating physician may  spend  a  half-day  per  week
              for 20 weeks in the institutional dialysis unit  or  he  may  elect
              an intensive period of daily sessions for two weeks.
                   B.  Coney Island Hospital - The Coney Island Hospital
              currently provides an extensive continuing education course in
              internal medicine for community  physicians.  It  is  anticipated  that
              the number and depth of lectures and  discussions  dealing  with  Renal
              disease will be increased with participation of  the  Coney  Island
              Hospital in the Regional  Transplantation  Program.  The  Coney  Island
              Hospital Speakers Bureau has  provided  lectures  on  various  aspects
              of-medical problems to interested community groups.  This program
              would be continued and the Renal aspects broadened bo  th as  an
              educational service and also as a means  of  informing  the  community
              concerning the necessity for,and activities of,  the  dialysis  and
              transplantation facilities. There  will  also  be  instituted  at  this
              hospital a training program for nurses and technicians which will
              take place under the supervision of the chief  dialysis  nurse  and
              the director of the Dialysis Unit.
                   C.  The Jewish Hospital of Brooklyn     This hospital  will  offer
              education in the area of Renal diseases to the lay community by having
              teams of nurses and physicians speak before groups such as the P.T.A.
              and religious groups.  They will also maintain contact with community
              physicians by attending meetings and speaking at the meetings of the
              county medical society and various  smaller  community  hospitals  and
              health clinics.
                   D. Maimonides Hospital - This  hospital  will  establish  a  staff
              and facility for the post-graduate education  of  visiting  staff  and
              interested physicians.
                   E. Prospect Heights Hospital -  This  hospital  will  establish  a
              comprehensive program for the education  of  community  physicians  in
              screening, recognition, diagnosis and  treatment  of  kidney  disease.








               NEW YORK RNP                     -5-               RM 00058  7/70.1


               The program will consist of at least two hours weekly  of  lectures
               and four hours of practical workshops for a period of  20  weeks.
               The course will be given twice yearly with identical syllabus,
               once at the Long Island College Hospital and once at  the  Bro6kdale
               Medical Center.

                    F. Staten Island Hospital - This institution  will  develop  an
               education program for medical, allied health personnel, patients
               and families in home dialysis.

               The target Population of this program will be all  patients  residing
                          p
               within this sub-region, all community physicians, and  allied  health
               personnel, and lay public.

               The Project Director will coordinate and make regular reports on
               the technical progress of the program including  the  participating
               institutions.


               The evaluation indices for the total program will include:  how many
               additional patients are served; the improvement in.quality  of  care
               and quantity of survival; the number of classified  personnel  that
               are trained; and the extent to which these personnel  have  benefited
               from the training.

               The Region has submitted a separate budget itemizing  funds  needed
               for planning and training purposes if the National  Advisory  Council
               still considers this the highest priority for RMP support.  The total
               requested by the combined institutions for the first year of support
               for planning and training purposes is $590,530.  Of  this  total,
               $484,318 is for personnel and $106,212 is for  equipment,  supplies,
               etc.


               Second Year:  $985,302              Third Year:  $1,092,014

               Project #17 - Harlem Region Stroke Program.  This project       Re(iuested
                             proposes to provide case finding, diagnosis       First Year
               and therapy services to control pre-strqke conditions and       $401,860
               to provide adequate therapy to minimize disability from
               stroke.  Submitted by the Columbia University College of
               Physicians and Surgeons and the Harlem Hospital Department
               of Medicine, the project will be a cooperative  activity  involving
               Harlem Hospital, Sydenham Hospital, Knickerbocker Hospital,
               Italian Hospital, the Upper Manhattan Medical Group, the
               Manhattan Central Medical Society, the Visiting Nurse Services
               of New York, the New York Health Department and its Central
               Harlem District Health Office, and other community  and  professional
               organizations.






               NEW YORK RNP                     -6-              RM 00058  7/70.1


               The target population is the Harlem Community which has a total
               population of approximately 450,000 persons of  whom  more  than
               150,000 are classified as  medically  indigent.  Cerebrovascular
               disease is a major disabling disorder in the  Harlem  community.
               The incidence of hypertension and related  pre-stroke  condition
               and the resulting cerebrovascular accidents in the socially
               deprived black population of communities such as Harlem is
               significantly higher than that in other segments  of  the  popu-
               plation of the country.  For example, at the Harlem Hospital
               19.2% of cerebrovascular accidents are in patients under age
               50, contrasted with a national figure of 4%.
               This project would initiate the following activities:
                    1) Establish a stroke program at.Harlem  Hospital  under  a
               project director and a full-time senior  neurologist,  who  will
               supervise daily operations and coordinate contributions  of  the
               many participating hospital  departments  (medicine,  neurology,
               rehabilitation, medicine, surgery, neuro-surgery, social services,
               radiology, home care, health education, and,ambulatory care
               services), as well as other agencies and other institutions
               participating in the program through cooperative arrangments. The
               director will be responsible to the  stroke  advisory  committee
               consisting of the directors of  the  participating  departments,
               plus designates from other hospitals and agencies.
                    2)  Expand the screening capacity of the out-patient clinics
               of Harlem Hospital to improve detection of stroke  and  pre-stroke
               conditions; a special hypertension unit will be established within
               the medical out-patient clinic to screen,  evaluate,  and  treat
               hypertension and related illness predisposing to stroke.
                    3)  Establish a three to four bed stroke intensive care unit
               and a comprehensive stroke treatment and  follow-up  clinic.  Both
               will be operated by a full-time neurologist under the direction of
               a project director.
                    4) Establish a training program  for  20  community  health
               workers in the technical aspects of stroke and pre-stroke
               symptomatology, screening and detection.
                    5) Establishment of a systematic  case-finding  network  to
               reach the undetected stroke and pre-stroke cases in  the  Harlem
               region, with particular emphasize on  hypertension.  Case  finding









               NEW YORK RNP                     -7-                RM 00058 7/70.1



               will be carried out by the Community Health Workers through an
               expanded recruitment and deployment pro.,ram in con unction with
               several community organizations actively supporting the  project;
               also in close collaboration with the Departments of Social Service
               and Ambulatory Services, the Central Harlem Health District of
               New York City Department of Health, and with community  agencies.

                    6)  Expand the training program for community paraprofessionals
               in health care and education related to stroke and focus  upon
               further career developments for these workers.

                    7) Participate in a training program for  registered  nurses
               and para-nursing personnel in intensive care for stroke and related
               cerebrovascular diseases throu    in age wit  an  ntensive care
               training program to be operated by the Schools of Nursing of
               Columbia University and Harlem Hospital.

               A delineation of the epidemiogical pattern of stroke in the
               Harlem area based on an evaluation of data gathered will be completed.

               Factors that will be considered in the evaluation of this  program
               will include:  additional patients served, quality of survival,
               morbidity rate, mortality rate, institutional agency  involvement,
               quality of care, geographic assessibility, system of medical  care
               delivery, training of skilled personnel, decreased costs, manpower
               training, and compare with similar programs elsewhere.  The Region
               has requested $1,173,035 for three years support of this  program.
               Through other sources of revenue, the program will  contribute
               $997,260 to the support of this program.  The major portion of funds
               requested from Regional Medical Programs will be utilized for personnel
               and equipment.

               Second Year:  $421,175                 Third Year:  $350,000

               Project #18 - A Project to Improve Interlibrary Loan  Services  Requested
                             and to Provide a Training and Consultation        First Year
                             Service for Medical Librarians.  This project      $88,958
               proposes to improve interlibrary loan services and to  provide
               training and consultation service for medical librarians.

               Through the interlibrary loan system, an additional 15 of  the
               larger hospitals will be encouraged to join the present 29
               members of the interlibrary loan and delivery service of the
               Medical Library Center of the New York Academy of Medicine.






               NtW YORK PM                      -8-             RM 00058 7/70.1


                                          itional hospitals to join, the center
               To make it possible for add
               will reduce its annual membership fee of $2,000 to $500 for the
               first year, $1,000 the second, and $1,500 the third yeari  In
               addition, it will add to its periodical holdings, 100 of the  most
               commonly used medical and other health-related journals to be
               made available to all members by loan or free photocopy along with
               the other journal holdings that the center makes available.  Members
               are also entitled to borrow from one another.  In all cases the
               material borrowed will be delivered directly by truck.
               In addition to the Medical Library Center aspect of this  program,
               the small libraries of the four Northern counties of this  Region,
               will have access to expanded facilities of the Westchester Academy
               of Medicine Library. Hospital libraries in Staten Island, Brooklyn,
               and parts of Queens will continue to be served by the Downstate
               Library on the basis of its resource grant from the National Library
               of Medicine; however, as NLM grant funds run out, the situation would
               be subject to review. Also as part of this proposal, both the Downstate
               Libtary and the Westchester Library will be linked by computer to the Medical
               Literature Data Bank of the New York Academy of Medicine to expedite their
               interlibrary loan activities.
               To run the training and consultation services, a central office will
               be established and a full-time trained librarian will carry out the
               following activities:
                    1.  Serving any of the Region's hospital library needs.
                    2.  Advise hospital administrators of standards of libraries and
               on- library personnel requirements.

                    3.  Set up training courses for librarians.

                    4.  Conduct or arrange seminars and workshops.
                    5.  Provide consultation to the Region's librarians on extension
               cataloging, acquisition, circulation, interlibrary loan and  other
               library systems.
                    6.  Help coordinate the Region's libraries, sharing of acquistion,
               and responsibilities.
                    7.  Visit hospital libraries periodically to see how security
               procedures are being implemented and to give encouragement to  the
               librarians.








               NEW YORK RNP                     -9-              RM  00058  7/70.1



                    8.  Evaluate the program of training and consultation.

               The hospital libraries with less than adequate facilities  will  be
               encouraged to enhance their holdings and their services at least
               to meet the everyday need of health professionals using them.
               Beyond that point, they will be served by interlibrary loan
               arrangements according to their needs.

               Collaborative arrangements exist with the Downstate Medical  Center
               Library, Medical Center Library of New York and the Regional Medical
               Library.  Discussions have already taken place with the administrative
               officials and the librarian of the Westchester Academy of  Medicine
               Library who are anxious to enhance their own library  activity  and
               are waiting to serve the four-county region.  A four-county committee
               for continuing education is presently spelling out the needs there.

               In phasing out the interlibrary loan system at the end of the three
               year period of support, it is anticipated that the new participating
               members of the Medical Library Center will be able to  assume  full
               costs. Cost of rental of computer systems would be assumed  by  the
               Downstate and Westchester Libraries.

               Phasing out of the training and consultation service.will  be  done
               by the Region's permanent library community which is in great  need
               of trained personnel absorbing the project personnel.

               The majority of funds requested in this proposal from MQ are in the
               category of personnel. The income acquired from graduated  fees  of
               new members of the Medical Library Center will make available a
               maximum revenue of $45,000.  Whatever revenue is acquired from this
               source will be deducted from the total requested from RNPS.

               Second Year:  $88,506                 Third Year:  $86,181







                       NEW YORK RMP                            -10-                      RM 00058 7/70.1


                                                         REVIEW AND FUNDING HISTORY


                       lst Year Planning Award                   6/l/67  -  5/31/68          Amount of Award $967,010 (d.c.o.)
                       ($98,785 of this award went
                        to Memorial Hospital Project
                        for Cancer and Allied Diseases)
                       2nd Year Planning Award                   6/l/68  -  5/31/69          Amount of Award $1,041,617 (d.c.o.)
                       Initial Supplemental Planning Award       6/l/68  -  5/31/69          Amount of Award $295,269 (d.c.o.)
                       (Earmarked Funds Awarded)

                            For Support of
                            Pediatric Pulmonary Disease
                              Center                                                         Funded (d.c.o.) $206,870
                            Mobile Coronary Care Unit                                        Funded (d.c.o.) $ 88,399
                       Second Supplemental Planning Award.       1/l/69  -  5/31/69          Amount of Award $76,000 (d.c.o.)
                       (August Council) (Continuation
                       Award for the Memorial Hospital
                       Feasibility Study)
                       Third Supplemental Planning Award.        6/l/68  -  9/30/69          Amount of Award $275,889
                       (Provided Indirect Cost for
                       Institutions Affiliated with the RNP)

                       Third Year Planning Grant Award           10/l/69 - 9/30/70           Amount of Award $1,480,136 (d.c.o.)

                            Includes Support of:
                            Core                                                             $1,104,648
                       #IR-Mobile CCU (St. Vincent's Hospital)                                    62,262
                       #6 -Regional Cancer Program (Memorial Hospital)                          155,760
                       #2 -Pediatric Pulmonary Program (Babies Hospital)                        157,466

                       1. Initial Operational Grant Award        2/l/70     1/31/71          01 year - $1,864,141 (d.c.o.)
                                                                                             Commitment
                                                                                             02 year - $1,864,141
                                                                                             03 year -  1,606,574


                       Includes Support of:

                            Core (Includes $44,194 for N.Y.                                  $1,245,658 (d.c.o.)
                            Health and Hospital Corporation,
                            and $141,010 for project #7 - A
                            Study of Facilities and Services
                            for Respiratory Diseases and
                            Disorders.)

                            #lR - Mobile CCU (St. Vincent's Hospital)                        $   62,262 (d.c.o.)
                            #2  - Pediatric Pulmonary (Babies Hospital)                         157,466 (d.c.o.)
                            #5  - Hemipl. Patient Care (Grasslands Hospital)                      25,997
                            #6  - Regional Cancer Program (Memorial Hospital)                   179,333
                            #9  - Education Program for Allied Health (Burke                    193,425
                                  Rehabilitation Center)

                       First Supplemental Operational Application
                       December 1969 Council

                       (The December 1969 Council deferred action on projects 010 and #13.  They were site visited
                       in February 1970 and March  Council  took  action  on  both  projects.)

                            #10 - Feasibility @loration and Demonstration                    Non-Approval II,
                                  Project in the Development of the Home as a                revision required
                                  Health Care Facility (req.  01  year  -  $667,764
                                  d.c.o.)







                       NEW YORK RMP                                                         RM 00058 7/70.1


                            #11  - Continuing Education of the Cormnunity                     Approval I - pending funding
                                   Physician - St. Luke's Hospital (req. 01 year
                                   - $73,810 d.c.o.)

                            #12  - Continuing Medical Education and Patient Referral          Approval I - pending funding
                                   for Community Physicians  (Brooklyn-Cumberland
                                   Medical Center, Brooklyn, New York) (req. 01 year -
                                   $70,636 d.c.c.)

                            #13 - Training Physicians and Allied Health Personnel in          Approval I - Pending funding
                                   Management of Chronic Renal Disease (req. 01 year -
                                   $181,300 d.c.o.)

                       Second Supplemental Operational Application
                       March  1970 Council

                            #14  - RMP Coronary Care Training Center at New York              Non-approval II, revision
                                   Hospital (Cornell University Medical College               requested
                                   (req. 01 year $105,520 d.c.o.)

                            #15  - Pilot Neonatal Special Care Center at New York             Non-approval II, revision
                                   University College of Medicine - Bellevue                  requested
                                   Hospital (req. 01 year $479,037 d.c.o.)





































                                                                                       DRMP/GRB
                                                                                     5/26/70




                                                                       (A Privi'l.egecl Coii,,fiiiii-iicitic)ti)




                                     SUji@RY OF REVII@l,%T AND CONCLUSION OF
                                           JUNE 1970 REV-EEW


                              NEI,L YORK @IETRO-POLI'rAN REGIONAL IIEDI-CAL PROGPA-M
                                                     "O@6.53:@ @@, 7
                                                 @l  0        /70. 1


                             FOR CONISIDEP\ATI'.ON  BY JULY 1970 ADVISORY COUNCIL


              'General:  The  Committee   recommended   the   following   action   on   this   application
                         which requests a total of $4-,51i-7,407 (d.c.o.) for three years
              support.  Committee took no action on Project #17 - I-larlem Region Stroke
              LE9                n7iended a technical site visit to determine  oca  participa-.
                       and recoT
              tibn in this program and negotiate an appropriate budget; disapproved
              Project l@16 -  @R(, ioiia I Program for Kidney Diseases for Brookly             d Statei.-I
              Is  LanJ,  and  disapproved  Project  #1-8  -  A  Proiect  to  Improve  Interlil)rL@y@o   @i
              Services and to Pro%7i-de a Trainiii5z and Consultation Service for Medical
              Librarians.

              Project #16 - A Regional- Program for Kidney Disease for Brooklyn and Staten
                               Island.

                           This is the third kidney disease project submitted by this
                           regi-on;   the  first  was  Project  #8  -  Treatment  of  Chronic  Fa  l@U
              SL@@@@9@e e@s
                                 _lLouiAt  Sinai  School  of  M  dici.n6,  which  requested  three   years
              support at a level of $2,310,615, and was disapproved by the August 1969
              Council;  and  the  second  was  Project  #13  -  Re  onal.  Program  for  Trai.li.ii  of
              IL@,y,-,ici.ans and Other Al-l-i.ed Ilealtli Disease Patients which requested
              $1,01@8,061, for three years support and the December 1.969 Council approved,
              the training portion of the project at a funding level. of $543,900 for
              three  years  support.  The  total  funds  requested   for   support   of   these   three
              Renal Disease projects tiMOUI).t@3 to $6,li.69,403.  Committee expressed concerns
              on the enormous amount of funds which can be easily spent in funding kidney
              disease  programs  and  believes  Council  should  take  a  close  look  c)i-I  how  and
              up  to  what  level  @IP  dollars  can  appropriately  be  spent  for  Ren.11-   Disease.
              Reviewers quc-,,;tionc!cl whether  l@N-IP  should  become  involved  in  supporting  the
              care of renal disease patients.        Committee expressed concern        over the
              R(@gion's I-acl@ of coordination in    planning  and   developing   these   three   renal
              disease @roposals.      There is no @'iiidj-citioi.-i in any of the-.se  projects  how  they
              fit  into  a  Regional  plan  for  kidney  disease.  There  appears  to   be   a   duplica--
              tion between projects rather than a coordii-iitccl c-@j'fo-i-t to assure t-liat variable
              component  services  are  implemented  and  coordinated  on  a  Regioi-iil.   basi@s,   such
              as: a Regional Ren'al Disease Center for patients who cannot have transplants-'
              tion  or  be  maintained  by  a  home  dialysis  program;  a  Regional  Ilome   Dial.ysis
              Program; a Regional Tissue Typing Center; a Reg:i.0-f-i.al- Organ Procurement Centci-;
              a  Regional  plan  for  dialysis  facilities  as  needed;   and   an   early   detection
              program.

                                  Nr,-@i-P@pl)j-oval T,-L -. revision required. It: is suggested that--
                                  the Region not@              i revised prc)j(@ct. uii-til- they  have
              developed a Regional- plan for kj.(Iiic@y disease iri.cl Lli(-,\t ha-@/--a clearly defined





            NEW YORK METROLP01TAN                      -2-                RM 00058  7/70.1
              Regional Medical Program
            policy from the RMP Advisory Council regarding areas of        support available
            from PMP for kidney disease activities.

            Project lbl7 - Harlem Region Stroke Program.

            Critique:  Committee  believes  this  project  is  well  planned  and  should   improve
                        the quality and quantity of health care for stroke patients in the'
            Harlem Conmiunity.  This  program  will  serve  the  total  Harlem  Community  which
            includes residents in the Model Cities area.  Conmiittee believes, however that
            the proposal  does  not  properly  explain  the  involvement  of  community  orgaiiiza-
            tions such as the  Minl)atten  Medical  Society  in  the  planning  and  operational
            phase  of  this  program.  The  involvement  of  Allied  Health  Professions  was  also
            questioned.  Concern  was  also  expressed  about  the  salary   structure   presented
            in the proposed bud,,et, which seems excessive.

            RecouL,nenda t ion: No Action Taken.   Committee recommended a site visit to
                               interpret community involvement and to negotiate an
            appropriate budget. Further, the  Committee  reconc,@,@ended  that  the  site  visit
            team be authorized to act in its-behalf in making  a  final  recofifiiieiidation  on
            this project.

            Project @18 -  A  Project  to  Improve  Interlibrarv  Loan  Services  and  to  Provide
                           q Trai-nirip, aiid Consultation Service for Medical Librarians..

            -.@it q@(-I: Committee believed  this  proposal  to  be  vague  and  nonspecific;  and
                        a]-most impossible of analysis in terms  of  activities  to  I)c,.  under-
            taken.  The  application  does  not  adequately  explain  the   relationship   between
            this Regional proposal and the Regional Medical Li.briry or the current Nc,@,7
            York State Interlil).-;7ary Loan System.  Committee  believes  this  Region   should
            @eek assistance from the Natioiial.  Libriry  of  Medicine  for  development  of  an
            interlibrary program that would maximize the utilization of existing resources
            within the Region.  Any plan which is developed should certainly take into
            account the follo,,iin- points:  a)  the  role  of  the  proposed  subregiolial  units;
            b) the proper role for  the  Medical  Library  Center  of.-New  York;  c)  the  defini-
            tioii of the relationship of  such  a  proposal  to  the  current  Regional  Medical
            Library, the Now  York  Academy  of  Medicine,  and  the  Medical  Library  Center  of
            New York; d)  the  necessity  and  desirability  of  computer  terminals  for  mono-
            graphic materials which  take  such  a  small-  percentage  of  the  interlibrary  loan
            needs; e) the need or advisability of subscribing to 100 journals at the Center,
            when these materials  are  widely  available  within  the  Region;  f)  more  detail
            concerning  the  role  of  the  Central  Consultation  Service  and  its  relationship
           .with  ongoing  consultation  and  education  activities  within  the  Region;  g)  pro-
            posed cost effectiveness of truck service compared with other means of delivering
            information; and h) improved plans for continuation under other support of all
            proposed activities.

            Recommendation:   Non-Approval I      No D@IP fundii-i  recommended.




                                                                      DI@IP/GRB
                                                                      7/10/70




             . 2













            0                                                              to                                                            0







                                Rf-@GIONAI, @IFDICAT, PRO@MS SERVICE
                    SUMMARY OF AN OPERATIONAL StJPPLEMNTPd, GRANT APPLICATION
                                     (A Privileged Comunication)


             NEW YORK NETROPOLITAN REGIONAL MEDICAL PROGRAM      RM 00058 7/70.2
             Associated Medical Schools                          June 1970 Review Committee
              of Greater New York
             2 East 103rd Street
             New York,  New  York  10029

             PROGRAM COORDINATOR:  I. Jay Brightman, M. D.
                   ted          lst Year       2nd Year        3rd Year        Total
             Direct Costs       $74,615        $73,790         $77,670           $226,075
             Indirect Costs       22,935        24,475          26,015           73,425

             TOTALS:            $97,550         $98,265        $103,685          $299,500
             HISTORY: Please refer to the NYMPM application    number  RM  00058  7/70.1.
             BACKGROUND:  This project was reviewed by Council in December 1969 under
                           the title Project #14 -      onal Iledical Program Coronary
             Care Training Center at New York Hospital - Cornell Universi        dical
                 e e. Although recognizing  that  the  project  was  technically  sound
             and capably directed, Council recommended that  it  be  returned  for
             revision.  It was suggested that nurse instructors be involved more
             in the didactic phase of the training; that  the  Region  develop  an
             overall plan for phasing out grant support;  and  that  the  Region  explore
             the possibility of the hospitals referring  trainees  to  assume  some  of
             the costs, particularly the trainee stipends.
             The Heart Disease and Stroke Control  Program  has  supported  a  coronary
             care training program at New York Hospital - Cornell Medical Center
             for about three years as part of  a  special  study.  This  contract  will
             terminate in Jtily 1970.  The NYMRNP is anxious to preserve and utilize
             the experienced personnel from this project for the development of a
             Regional Training Center in Coronary Care.  In  order  to  meet  this  need,
             Dr. 1. Jay Brightman, Coordinator,          has requested that the revised
             project be considered with urgency.
             PRESENT APPLICATION: This  application  is  requesting  $299,500  for  three
                                    years'support of a  coronary  care  training  project
             for nurses. It is a resubmittal of  Project  #14,  which  has  been  revised
             and the amount requested reduced from $3i7,941 (d.c.o.) to $226,075 (d.c.o.).






              NEW YORK METROPOLIT&N RMP         -2-              FIA 00058 7/70.2

              Project # 19 - New York Hospital. Cornell Medical Center         Requested
                              Program for Continuing Education for Nurses.     First Year
              Recently published statistics indica@e that in 1966 there        $74,615
              were an estimated 205,000 persons having acute episodes of
              coronary heart disease and 31,000 deaths frorm  myocardial  in-
              farction in the Metropolitan New York  area.  The  Region  states
              that 5,000 to 7,500 deaths could be prevented in the Metropolitan
              New York area each year if effective coronary  care  facilities  were
              available in most of the hospitals in this area.
              The Region projects a need of 2,428 CCU/ICU  monitored  beds  and
              approximately 2,400 trained nurses to staff them.    In view  of
              the present turnover figures the Region expects  it  would  have
              to train 1,000 nurses per year, of  which  approximately  370-400
              nurses would remain active on CCU staff.
              In 1968 questionnaires were sent to 150 of  the  estimated  181
              community hospitals in this Region; sixty-one replies were
              received.   Twenty-nine of these community hospitals  indicated  a
              definite interest and proposed sending at least 156  nurses  to  a
              coronary care unit training course during  the  following  year.
              The Region has developed a master plan to develop  five  to  ten
              Cardiovascular Training Centers in the  region  to  upgrade,the
              preparation of the graduate nurse practitioner  within  the  area
              of cardiovascular disease nursing so that  adequate  numbers  of
              prepared nurses will be available to  function  effectively  in
              Intensive Care Units and other related service areas.
              The Regional plan also includes the establishment  of  a  Regional
              Council of Training Program Directors from the proposed participating
              regional centers for CCU training.  This Council, under the auspices
              of the NYMPM and the Heart Associations of this Region would be
              charged with the establishment of uniform standards for training,
              evaluation and supervision of these  regional  training  programs.
              This approach will give the region a system of control over the quality
              and quantity of CCU Training Programs in the Region.
              This project proposes to develop at the New York Hospital - Cornell
              Medical Center the first primary center for  Coronary  Care  Training
              of nurses within the NYMRNP master plan. It will  serve  as  a  model
              for the development of other high quality  nurses  coronary  care
              training program throughout the  Region.  The  training  center  will
              provide an intensive thorough four-week long  course  in  coronary
              nursing care four times each year for at least three consecutive
              years (1970-1972).   Registered nurses with  leadership  positions
              (supervisors, nursing instructors, head nurses and assistant head





                NEW YORK METROPOLITAN RMP      -3-               RM 00058 7/70.2

                nurses) from hospitals in the nine-county metropolitan New York
                area will be accepted as trainees in the Coronary Care Training
                Course.  Criteria for the selection of trainees into the program
                will emphasize nursing instructor trainees from basic education
                programs and in-service educator trainees from hospital settings.
                The primary purpose of the training center will be to train the
                nurses well enough that they will be able to set up and administer
                programs for CCU staff nurse training in their sponsoring hospitals.
                This could be an in-service continuing education activity in a
                hospital- or a coronary unit training course in a nursing school
                basic education program.  It is expected that this center will
                train 120 nurses on an annual basis.  Both physicians and nurses
                will actively participate in teaching, planning, implementing,
                and evaluation of the educational activities.  The nurses and
                physicians will work together to identify components in the
                training program which serve to enhance the development of
                knowledge and attitudes required by the nurse to accept and assume
                a changing role in relation to the physicians and other members
                of the health team.  It is believed that this interaction will be
                crucial to the delivery of health care services for patients with
                problems other than coronary heart disease. In addition to the
                instructors which will be assigned to the course, faculty members of
                the School  of Nursing, Medical College, and staff of the Center
                will serve to advise and/or participate in the program.
                The facilities of the Cornell University - New York Hospital School
                of Nursing will be available to conduct this course.  These
                facilities include classrooms, laboratory and the Coronary Care
                Unit of the Medical Center.
                A newsletter will be developed and distributed to former trainees,
                hospitals and schools to promote continuing follow-up of current
                advances in the field of cardiovascular disease.
                The applicant estimates the cost per trainee will run in excess of
                $1,000 and that the trainee or her sponsoring institution could not
                assume this cost. The program plans to charge no tuition  or  fees
                during the first two or three years. Trainees who have  to  occupy
                temporary quarters will be provided with a daily per them of $16
                or $80 per week.  Transportation  costs will be assumed by the
                sponsoring hospital. It is anticipated by the Region that  70%  of
                the students will be able to commute on a daily basis. The per
                them rates stipulated above are within RNP policy limitations  but
                the individual must travel a minimum of fifty miles round trip  in
                order to be eligible.





            NEW YORK METROPOLITAN                                RM 00058  7/70.2

            For evaluation students will be given a pre-test  and final evaluatio
                                                                                 n.
            Questionnaires will be sent to students and their  nursing  directors
            six months after completion of the course.  Site visits will be,
            utilized to determine not only how effective the students function
            in tieir own hospital but also to identify the difficulties they have
            encountered since their return.  In addition the associate nurse and
            physician directors of the traini;%g course will review and  evaluate
            existing training programs  in the community hospitals that send
            personnel to the Regional Center.  Efforts will be made to standardize
            the curriculum of the in-service coronary care training  programs  in
            community hospitals after the preceptors who will administer them
            have been trained.
            The Region plans to continue this program once RNP funding is
            terminated by implementing a tuition payment plan.  The major portion
            of funds requested are for support of personnel and the payment of
            stipends for trainees.
            Second Year:  $73,790                   Third Year:  $77,670



















                                                      D@/GRB
                                                      5/22/70




                                                                 (A Privileged Communication)




                                  SIKLIARY Ol,,' RFVIEI,L AND CONCLUSION OF
                                       JUNE 19.70 RI-I'Vll',"W CO@IMITTEE


                             NEW YORK METROPOLITAN RL,,GIONAL I,-IET)ICAL PROGRAM
                                             P@l 00058 7/70.2


                           FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


             General: This application requests  a  total  of  $226,075  for  three-years
                       support of Project,@tl9 - New York Hospital Cornell Medical
             Center Pro,-ram for  c)ntir)u@Li@Eci c-@a on of 1,@ux-seG. Committee    approved
             partial funding of this application at a lev.-l@of- $11-5,125  (D.C.O.)  for
             two-years support.
             @a@ o@tin@: This project was reviewed by Council in December 1969 under the
                          title  Project  #14  -   @ional   Medic@P
                                                                  .@o
                                                                     ,,Kam   Coronary_@re
             TLrai@n Center  at  New  York  Hospital  -  Cornell  University  Medical  Col@e.
             Although recognizing that the project  was  technically  sound  and  capably
             directed, Council recommended that it  be  returned  for  revision.  It  was
             suggested that nurse instructors be involved  more  in  the  didactic  phase
             of the training; that the Region develop  an  overall  plan  for  phasing  out
             grant support; and that the Region explore the possibility of the hospitals
             referring trainees to assume some  of  the  costs,  particularly  the  trainee
             stipends.

             The Heart  Disease and Stroke Control Program has supported a coronary
             care training program at New York Ilospital -  Cornell  Medical  Center  for
             about three years as part of  a  special  study.  This  contract  terminates
             in July 1970.  The NYL'@IRMP would like to preserve and utilize the experienced
             personnel from this project for  the  development  of  a  Regional  Training
             Center in Coronary Care. In order to meet  this  need,  Dr.  1.  Jay  Brightnia n.
             Coordinator 31 NYDIPMP has requested that the  revised  project  be  considered
             with urgency.

             Project #19 - N.Y. Hospital Cornell Medical  Center  Program  if-or  ContinuinR
                            Education of Nurses

             Critique: The Committee believes that for  the  most  part,tlie  Region  has
             ilti-s-@ctorily answered the questions posed  by  the  December  1969  Council
             and that this project will produce much neededaettiit-;-onal trainees.    The
             Committee however, still believes that  there  should  be  more  involvement  of
             nurses and nursing schools in  the'implementation  of  this  program  and  that
             the program should give a guarantee that  other  sources  of  support  will  be
             available at the conclusion of twoyears'when RMP support terminates.       Coiii-
             ruittee also foals that participating hospitals  should  contribute  to  the
             cost of training their own personnel  by  assuming  the  costs  for  stipends.
             In view of past support by the USPIIS and Councils previous concern for phas-
             in(y out the grant support Committee believed that  two  years  support  by  the
             DRMP should give the Region sufficient  time  to  develop  an  established  Pro-
             gram which can be locally supported.




            NE14 YORK METROPOLITAN RMP                   -2-             RM 00058 7/70.2



            The Committee concurred with the Ad Hoc.Cardiovascular Panel's favorable
            review and recognized the project as technically sound and capably directed.

            Recommendation:  Approval I - at a reduced level with the following con-
                              tingencies: (a) That nursing school participation can be
            clearly identified; (b) that the Region can give assurance of continuing
            support from other sources for the program at  the  end  of  two-years  support
            from the DRMP, prior to release of funds for the first year's support;
            (c) that the participating hospitals assume the costs  for  stipends  of  n  r-
            sonnel they refer for-training.    The amount requested for'@ti e@ri@- ($33,280)
            has been deducted from the requested level.



                    First Year                    Second Year             Third Year
                     $57,975                        $57,150                $ -0-



                              REVIEW CO,%@IITTEE FUNDING RE-COi4MENDATION (D.C.O.)


            Project                  Year                 Recluested             Recommerided

            #19                      01                   $74,615                   $57,975

                                     02                     73,790                   57,150

                                     03                     77,670                    -0-


                             TOTAL                        $226,075                 *11-5,12@









                                                          IOIPS/GRB/7/8/7b





                                                                                DRAFT


                                         SITE VISIT PI,'.I'ORT


                          NEW YOI@ METROPOLITAN REGIONAI@ MEDICAL PROGRAM
                                            J.@l 00058


                                           JULY 21, 1970


           Site Visitors


           Dr. John D. Thompson
           Professor of Health and
           Associate Dean for Planning
           Yale University School of Medicine
           New Haven, Connecticut


           Jessie B. Barber, Jr., M.D.
           Consultant, RIIPS
           Professor of Neurosurgery
           Howard University School of Medicine
           Washington, D.C.

           Division Regional Medical Programs Service


           Mr. Cleveland R. Chambliss
           Office of Organizational Liaison


           Mr. Bob Morales
           Public Health Advisor
           Grants Review Branch


           Regional Advisory Group Members

           John L.S. Holloman, Jr., M.D.
           RAG and TCP - Stroke Member


           Regional Medical Programs Service Core Staff

           I. Jay Brightman, M.D.
           Director
           New York Metropolitan
           Regional Medical Program


           Jessie Aronson, @I.D.
           Deputy Director

           Mrs. Margaret Barnett
           Program Representative


           Mrs. Fredrica Brooks
           Assistant Director for
           Administration and Communications




            l@'E@4 YOIIK MLTPOPOLT.TALI                                     R@l 00058
              Regional Medical Program


                    _@@e  P-@ntatives

            Ralph W. Rechter, M.D.
            Project   Co-Director

            Charles A. Ragan, M.D.
            Project   Co-Director

            George I. Lythcott, M.D.
            Columbia  University  and
            Harlem Hospital

            Bernard  Challenor,  M.D.
            Colun,bia University  and
            Harlem Hospital

            Miss  Barbara  Bengan
            Columbia  University  and
            Harlem Hospital


            Others


            Mr. Preston Lewis
            Model Cities


            Mr. George Goodman, Director
            i@,@trlem Neighborhoods Association

            Mr. Leo Rolle,
            Executive Director
            United Block Association


            Mr. George Lotham
            Executive   Secretary
            United Block Association







             NEW YOIU,, @1F.TROPOI@ITAiN              -3-                     PM 00058
               Regional Medical Program

             I,lc k L
                  @ound:  In June 1970   the  Review  Committee  reviewed   an   operational
                           supplement application from the New York Metropolitan
             Regional Medical Program which included Project #1-7 - Harlem Rc@,ion
             Stroke Program.  Committee took no action on this project and recolii-
             mended a site  visit  to  interpret  community  involvement  and  to  negotiate
             an appropriate budget.    Further, the Committee recommended that the site
             visit team be authorized to  act  in  its  behalf  in  making  a  final  recom-
             mendation on this project.

             Concerns:  The  questions  raised  for  consideration  by  the  site   visitors
                        were  the  following:  (1)  What  is  the  involvement  of   profes-
             sional and community organizations such as the Manhatten Medical Society,
             Block Association, and private practitioners in the planning and
             implementation  phase  of  this  program;  (2)  What  is  the  involvement   of
             allied health personnel  in  the  planning  and  implementation  of  this  pro-
             gram;  (3)  How will speech therapy and other rehabilitation services
             be provided by this program; and (4) Is the salary structure in the
             proposed budget appropriate?

             Project #17 - Harlem Region Stroke Program

             Dr. I. Jay Brightman initiated the meeting by commenting on the Region's
             enthusiasm  and  interest  in  this  project.  He  mentioned  that  Dr.  George
             I. Lythcott, M.D., the NYM/@ representative at Columbia University,
             has  been  quite  involved  with  community  activities  in  the  Harlem  area,
             including this Stroke Program.

             'JI.ie site visit team recognized the  limited'involvement   of   both   profes-
             sional and community organizations in the planning phase of this program.
             The team, however, identified from the testimony of able representatives
             at the meeting, that there will be much more involvement of all
             community organizations in the implementation phase of this program.

             Dr. Charles A. Ragan, Project Co-Director, explained that the participating
             hospitals (Sydenham, Knickerbocker Hospital, Italian Hospital) have only
             limited  services  for  the  stroke  patient  in  their  facilities.   Although
             a firm commitment cannot be given unless this project is funded, the
             Harlem Hospital has made a verbal agreement with these facilities to accept
             referrals of stroke patients, both indigent and non-indigent, to this
             program.  Dr. Ragan explained that these hospitals were not too involved
             in the planning phase  because  there  have  been  no  previous  successes  and
             some insensitivity to needs of the community in previous program develop-
             ment attempts. Each  of  the  hospitals  will  have  a  representative  on  the
             Advisory Committee of the program.

             The Region agreed with the site team's concerns that the Manhatten Medical
             ociet v  should  be  more  involved  with  this  program.  They  indicated  that
             they are work4@ng toward gaining the Society's increased participation





            NE@4 YO]@l@ I,-IF.TROPOLI'J'A:""                               l@l 00058
              Regional Medical Pro@rar@i
                                   4-1

            and involvement with the program.  Many of the Society's members are
            indirectly involved by participating in total  hospital  planning  a]-tliou-h
            not particularly with this program . Of, a seven  member  Executive  Coimiiittee
            of the Society, five are on the Department of Medicine Staff at Harlem
            Hospital. A representative of the society will be  on  the  prograui's  advisory
            committee.
            The Rehabilitation Department of  the  Harlem  Hospital  will  provide  complete
            rehabilitation services (including speech therapy) to patients entering in the
            program.
            Input into this program by  'allied health       i-inel has come primarily  from
            staff of the Rehabilitation  Department  it  Harlem  Hospital.  These  personnel
            have been primarily involved with the  development  of  the  curriculum  for
            training the community health workers identified  in  the  proposal  and  will
            participate as instructors. They will  also  be  involved  in  the  treatment
            of patients, the evaluation of the program,  and  will  be  represented  on  the
            Advisory   Committee.

            A strong facet of this project which was of  interest  to  the  site  visitors
            .was the Block Association, a community organization in the Harlem area
            which will participate in  this  program.  This  organization  remains  active
            in the Harlem Community by helping to  locate  health  services  needed  by  the
            population in their area. They  have  much  interest  in  health  prevention
            programs and have had experience working with the lead poisoning and
            tuberculosis programs. The Block  Association  believes  they  can  take  an
            active role in the detection, education  and  follow-up  phase  of  this  stroke
            program.  The representative from the Harlem Neighborhood Association
            C,XPT.cssed his organizations interest and willingness to cooperate with
            the  program.  The  H'arlem-East  Harlem  Model  Cities  representative  indicated
            that his program supports the Harlem  Regional  Stroke  Program  which  will
            serve the Model Neighborhood Area that  includes  more  than  100,000  residents
            of Central Harlem. The Urban League has  been  invited  to  participate  in  the
            program and continued efforts will be made to gain their involvement       The
            site visit team believes that it was able to,convey to t@ community
            organizations the message that  the  @  encourages  them  to  become  involved
            in planning and implementation  of  health  programs  in  their  community.  All
            four of these community groups will  have  representatives  on  the  Advisory
            Committee.

            The site visitors believe that the salary  and  equipment  proposed  in  the
            pro-iect's budget is realistic and may    possibly need  to  be  supplemented
            through local resources.  The applicant in addition to the $997,260 outlined
            in the application as its contribution to the  support  of  this  project,  will
            be contributing an additional $50,000 to $100,000 in personnel and equipment,
            such as speech therapist, EEG, Echo Testing Equipment, blood gas determination
            equipment, etc.
            The project representatives  indicated  that  the  evaluation  of  this  program
            will be strengthened by the availability of retrospective data on hypertension





            NE@@' YORK YiETPOPOLITA'@@l-             -5-                   Izil 00058
              Regional @Ic-dical Program

            of residents from the Harlem community  which will be available from
            a community study and a hospital chart   stud.v at Li-ii,coli-i Hospital that-
            has been in operation for two years.  The  site  visitors  believed  that
            the evaluation proposed by this project is adequate.

            The project representatives believe that it may.])e possible for the
            city government to absorb this program if it  proves  to  be  successful
            at the end of three years' support by P@IP.  They indicated that history
            has shown that successful programs have been absorbed  by  the  city  and
            cited a mental health program as an example.

            Conclusions: The site team believes that  the  concerns  of  the  Review
                          Committee have been more than adequately answered by the
            project representatives present at the site visit.  It is clear that there is
            professional, community and allied health involvement and that the budoet
            is realistic. In addition, the proposal  has  other  positive  aspects  such
            as the close cooperation of the Department  of  Medicine,  the  proposed
            involvement of other poorly staffed and equipped  hospitals  in  the  Harlem
            Region, the availability of existing  community  organizations  for  case
            finding and follow-up and the obvious  interest  of  well-qualified  profes-
            sionals in the region.  The site team is impressed over the preventive
            aspects of t@ proposal as well as the proposed diagnosis and treatment
            activities.  It could be a welcome contribution toward solving the problem
            of CVA particularly in this stroke-prone population.  In addition,
            the site team recognizes the high professional caliber of project staff
            and the support it is receiving from community  organizations  such  as  the
                  Cities Program, Harlem Neighborhood  Association,  and  the  United
             Lock  Association.

            Recommendation:  Site visit team recommends that this project be supported
                             for three years at the requested level of funding.




                          SUMMARY OF RECOMMENDED FUNDING IN DIRECT COSTS

            Project          Year               Requested            Recommended

            #17 - Harlem      01                 $401,860               $401,860
            Region Stroke     .02                 421,175                421,175
                ram           03                  350,000                350,000

                          TOTAL                $1,173,035             $1,173,035







                                                           DRMP/GRB
                                                           7/27/70

















            0                                                              0                                                              0







                                  REGIONAL MEDICAL PROGRAMS SERVICE
                    SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION
                                    (A Privileged Communication)


            NORTH CAROLINA REGIONAL MEDICAL PROGRAM                      RM 00006  7/70.1
            4019 North-Roxboro Road                                      June 197-0
            Durham,  North  Carolina  27706                              Review Committee

            Program Coordinator:  F.M. Simmons Patterson, M.D.
            Requested             lst  Year        2nd   Year       3rd  Year        TOTAL
            Direct Costs           $213,813          $197,153        $177,340         $588,306
            Indirect Costs           37,428            52,913          56,711          147,052

                  TOTAL            $251,241          $250,066        $234,051         $735,358
            HISTORY: The planning grant period was for  two  years,  July,  1966-June  30,  1968.
                      During the first year $438,851 was  awarded  and  $773,674  the  second.
            In November 1967, a site visit was made to appraise the Regionis capability
            for operational status. Initial operational  support  was  being  sought  for  core
            staff and nine projects.  The visitors recognized a lack of an overall state
            plan for Regional development. Program  development,  however,  was  in  the  early
            stages and corrective resources were  available.  The  site  visitors  were  highly
            impressed with the Region's Research  and  Evaluation  Division's  continued  parti-
            cip6tion and input into the programs.

                                                                 ion became operational
            As recommended by Council in February 1969, the Reg
            with an initial award in the amount of $1,485,341 for  the  support  of  core  staff
            and eleven projects.  In May 1968, Council approved four of five component
            projecIts in the first  supplemental  application.  Disapproved,  the  project  for
            coronary care training for physicians and  nurses  was  returned  for  revision.  In
            November 1968, Council approved the second supplemental application for the
            support of two more projects, one being a revision  of  the  coronary  care  training
            proposal. In February 1969,  Council  approved  a  third  supplemental  application
            consisting of one new project and a request for  additional  funds  for  anot  er.
            In May 1969, Council approved four of five  components  in  the  fourth  supplemental
            application. The  disapproved  project,  Physicians  Assistant  Training  Program,
            was returned for revision. It was revised  and  submitted  with  four  new  projects
            in the fifth supplemental application; all were approved by Council in
            August 1969. In December 1969,  Council  approved  the  sixth  supplemental  applica-
            tion consisting of two new pro, ects. Council believed  that  one  of  the  projects,
            Medical Student Operation of Edgemont Clinic  (#24),  could  be  supported  through
            the core staff budget without additional  grant  support.  In  March  1970,  Council
            recommended approval of the first renewal application consisting of two projects.
            In May 1969, DRMP staff reviewed the non-competing second year operational
            continuation grant application consisting of  core  staff  and  14  projects.  The
            individual project progress reports were in very general terms and faile  to
            clearly specify progress in terms of stated objectives.  There was also a
            scarcity of information about projected  accomplishments  in  the  following  year.
            The core staff report, however, indicated that much more had been achieved
            than was reflected in the individual reports.  Based on information in the




           NORTH CAROLINA Regional Medical Program        -2-               RM 00006  7/70.1
           in the core staff report, it was believed that there was substantial
           evidience of significant regionalization progress.  Approval was recommended
           resulting in an award in the amount of              d.c.o.) including
                    rryover funds in Core.
           A summary of the "Review and Funding History" is attached for reconciliation
           ease.
           PRESENT APPLICATION:  Support is requested for two projects; one is a renewal.
                                                                                      Requested
           Project #3R - Diabetic Consultation and Educati                This        First Year
                        project was initially funded for two years and four            $89,908
           months, March 1, 1968-June 30, 1970, $132,081 (d.c.o.) the first
           period (16 months)and $79,442 the second period (12 months).
           The principal aim of the project was to bring advances in diabetes
           management to physicians, nurses and patients and their families in
           local communities.  This was to be accomplished through seminars and
           other educational programs.  As a pilot program, these services were
           to be delivered statewide by three teams.   Goals  included  the   expansion
           of consultation and teaching clinics in two hospitals, assistance in
           organizing a state association for the  control  of  diabetes,  and  testing
           data collection techniques.
           During the twenty-four months of operation, four major activities have
           evolved.  One hundred and one  (101)  professional  education  programs,  20
           for physicians and 81 for paramedical personnel, were conducted in 28
           different counties reaching a  total  audience  of  3,166.  Consultation  by
           staff physicians and nurses was offered in conjunction with the continuing
           education program.  In addition to direct  patient  teaching,  the  Diabetes
           Teaching Nurses were active in screening programs, inservice training for
           nursing personnel, public education,  arranging  for  diabetic  children  to
           attend a special summer camp and organizing local diabetes societies.
           Numerous publications, i.e., references for physicians and nurses, patient
           guides, news bulletins and professional papers, were published and widely
           distributed.  A major accomplishment was the formation of the North Caro-
           lina Diabetes Association, now an affiliate of the national parent
           organization.  Present evaluation methods include program interest surveys,
           testing prior to programs, data collection, periodic reporting of activities
           and program response.
           Renewal support is requested for an additional three years to develop
           a broad lay and professional educational program  to  be  continued  by  the
           North Carolina Diabetes Association  after  cessation  of  Federal  support.
           Planslinclude:   1) continued educational activities for physicians,
           nurses and allied health personnel, and patients and their families;
           2) multidisciplinary workshops; 3) expanding consultation service to
           include a dial access system, a new project being proposed to NCRMP;
           4) use of available educational material, as well as the development and
           testing of new publications and 5) establishment of a central office.




           NORTH CAROLINA Regional Medical Program         -3-            RM 00006  7/70.1

           Plans also call for the provision of an organizational framework
           compatible with the North Carolina Diabetes Association's goals
           and functions.  This will facilitate their eventual takeover.
           Evaluation will also provide for measuring changes in behavior
           as a result of inservice education programs.

           Approximately 90% of the budget is for personnel including
           $41,936 for contracting for the services of eight Diabetes     Teaching
           Nurses; four are new positions.  The  applicant  expects  that  support
           .for four of these positions will be assumed locally  after  the  first
           year and four by the North Carolina Diabetes Association in the
           third year.

           Second Year:  $62,550                     Third Year:  $42,306

                                                                                        Requested
           Project #26 - Emphysema and Lung Disease  Program.  The  overall  goal  of   First Yea@
                          this project is to achieve a position in which every           $123,905
           citizen of North Carolina can obtain, within 50 miles of their homes,
           the most up-to-date diagnostic and  treatment  services  for  pulmonary
           disorders. Short term  objectives  during  the  first  year:  1)  develop-
           ment of a regional Pulmonary Training Center at Duke University
           Medical Center at Durham; 2) improvement of  diagnostic  and  treatment
           capabilities of four hospitals located in the  communities  of  Shelby,
           Wilson, Greenville and Winston-Salem and 3)  implementation  of  a  formal
           communication link-up between  participating  institutions  to  provide
           for consultation, improved referral resources  for  private  practicing
           physicians and increased public awareness  of  respiratory  disorders  and
           the services necessary for  their  control.

           Through planning the project, working  relationships  have  already  begun
           between the project director, assistant directors and the representatives
           of hospitals (including the V.A. Hospitals),  medical  schools  and  State
           Sanitariums. Two State Sanitariums  located  in  Asheville  and  McCain
           alreadyhave the capability and will serve as referral centers for the
           western and southeastern parts of the state.
           During the first year, the training center will train  36  persons  (12
           physicians 1-4 weeks, 12 nurses 2-6 weeks and 12 pulmonary laboratory
           technicians 8 weeks). Initial enrollment  will  be  limited  to  personnel
           from participating hospitals and the length of  the  course  will  vary
           pending on the individual expertise of those to be trained.

           The Project Director, Assistant Directors  and  the  Training  Director
           assisted by other program participants, including NCRMP core staff, will
           periodically assess the program.  Evaluation  will  include  appraisal  of
           productivity and capability of community care facilities, patient,,oork-
           loads, physician and health care  personnel  involvement  including  those
           in training and/or in need of it, and annotational data.





          NORTH CAROLINA Regional Medical Program       -4-

          Near the end of the first year, an internal evaluation will be
          undertaken.  If the program is progressing as planned, two new.
          training centers will,be established during the second year  one
          in Winston-Salem and one in Greenville.  If not, approximately
          $35,000 will be rebudgeted to establish or improve care centers
          in one hospital in each of the five communit ies of Wilmington,
          Raleigh, Rocky Mount, Fayetteville and Charlotte..

          Support requested is the sum of six sub-project budgets.  A
          composite of the budgets,is attached.  McCain Sanitarium is
          cooperating as a referral center, but is not requesting grant
          support.





                                                                                                     7 / 7 0I
             NORTH CAROLINA Regional Medical Program                -5-                  RM 00006


                                            REVIEW AND FUNDING HISTORY
             lat Year Planning Award                  7/i/66-6/30/67                             287,266
             (June 1966 Council)
             01 Supplement                            I/l/67-6/30/67                             148,585
             (Site   visited   November    1966)
             (November 1966 Council
             2nd Year  Planning Award                 7/l/67-6/30/68                             600,944
               02 Supplement                          9/l/67-6/30/68                             172,730-

             INITIAL OPERATIONAL APPLICATION COMPONENTS
             (Site   visited   November    1967)
             (February 1968 Council)
                                                      Approved                                     Approved
                                                   Project Period         Funded (d.c.o)         Future   Level
             #0  -  Core  Planning   and   Staff      3 yrs               (01)$530,991           (03)$589,130
                                                                          (02)    586,629
             #1   -Education   and   Research   in    3  yrs-4  mos.      (01)    209,200        (03)   240,993
                   Community    Medical    Care-                          (02)    201,119
                   University of North
                   Carolina
             #2    Coronary    Care     Training      3  yrs-4  mos.      (01)     65,823        103)    84,067
                   And   Development   -    Duke                          (02)
                                                                                ,04P
                   University'c
             #3   -Diabetic    Consultation    and    2  yrs-4  mos.      (01)    132,081        (03)       -0-
                   Education   -    Duke    University*                   (02 )
             #4   -Development    of     Central      3  yrs-4  mos.      (01)     66,615        (03)   125,510
                   Cancer   Registry   -   Univer-                        (02)    111,188
                   sity   of   North    Carolina
             #5   -Medical    Library    Extension    2  yrs-4  mos.      (01)   25,839          (03)       -0-
                   Service-Duke       University                          (02)   23,763
             #6   -Cancer Information Service         2  yrs-4  MOS.      (01)   .141,716        (03)       -0-
                   Duke University                                        (02)   31,014
             #7   -Continuing    Education    in      3  yrs-4  mos.      (01)   :24,428         (03)   23,834
                   Internal Medicine - Uni-                               (02)   :21,253
                   veristy   of   North   Carolina
             #8   -Continuing    Education    in      3  yrs-4  mos.      (01)   Ei7,500         (03)  6 7
                   Dentistry    -     University                          (02)   C-)I,041
                   of North Carolina





                                                                                                                  00006  @@;7@/,-70. 1
             NORTH@CAROLINA Regional Medical Program                                                         RM:

                                                                 Approved                                                AvDroved
                                                                Proiect Period,,,. '.,Funded. (d.c.o.)                 Futur(
             #9      Cdhtinuing Education for                    3.', yr s -4 mo a        (01)$r27,838@,.@,j.!@i--,  (03)$      28,381
                     Physical           Therapists                                        (02)   25@543.@@,f@,@,
                     University      of      North
                     Carolina
             #10-    Coronary     Care       Units  in          3 yrs-4 mos.              (01)   99-,,.9$9,            (031);3.7,042
                     Small Hospitals  (State                                              (02)   33,338
                     of Franklin)  - Bowman
                     Gray*

             #11-    Mobile Cardiac Intensive                   I yr-3    mos.           ..r,(Ol) 18,485,              (03),:        -0-
                     Care  - Haywood Ccrmnty                                              (02)        -0-:@:,
                     Hospital*

             COMPONENTS       OF       FIRST       SUPPLEMENTAL
             OPERATIONAL APPLICATION
             (May 1968 Council)
             #12-    Regional Coronary Care Unit Disapproved with,advice to                              Revise    and Resubmit
                     for     Physician     and      Nurse
                     Education     -     Bowman      Gray
             #13-    Cardiopulmonary Resuscita-                 3     yrs-I    mo.        (01)@@60,86:1               @@,(03)     70,056
                     tion - Duke University and                                           (02)   63,152
                     North      Carolina      Heart      Assoc.

             #14-    Heart Consultation and                     3     yrs-I    mo.        @(01)    9    595@:          (03)     8,720
                     Education     -     Bowman      Gray                                 (02)     7,848.
             #15-    A Community       Stroke Program           3      yrs-l,mo..        ;@@(01). 152@,37.5,           (03)        258,740
                     Bowman    Gray@.,.@..-..,                                            .@(Q2) 172,930
             #16-    A      Community      Program@for      the 3.yrs-l-mo.               (01)     38)865              (03)     31,206
                     Early     Detection.      and      Manage-                           .(02)    28,085
                     ment of Hypertension
                     University      of      North
                     Carolina*


             COMPONENTS OF SECOND                    SUPPLEMENTAL
             APPLICATION
             (November  1968 Council)
             #12-    Regional      Coronary      Care      Unit 1  year                   (01)     90,00o,il-I         (02)(03)        -0-
                     for     Physician     and      Nurse
                     Education     -     Bowman      Gray
             #17-    Regional     Center     for     Gesta-     3     years               (0l)-       29,,OOO                   29,000
                     tional Throphoblastic                                                                             (03)         29,000
                     Neoplasms      -      Duke      University





           NORTH CAROLINA Regional Medical Program             -7-              RM   00006    7/70.1

           COMPONENTS  OF   THIRD   SUPPLE-
           MENTAL     APPLICATION
           (February   1569   Council)
                                                   Approved                                  Approved
                                                 Project Period      Funded (d.c.o.)       Future    Level

           #2    Supplement   to   Coronary       3 years            (01)    23,584        (02)$    23,584
                 Care Training and                                                         (03)     23,584
                 Development

           #18-  Tumor  Tissue  Registry   -      3 years            (01)     6,916        (02)    6,916
                 Moses  H.  Cone   Hospital,                                               (03)    6,916
                 Greensboro


           COMPONENTS  OF   FOURTH   SUPPLE-
           MENTAL     APPLICATION
           (May   1969   Council)

           #19- Physician's Assistant            Disapproved with advice to Revise and Resubmit
                 Training Program

           #20@   Mammography    Technologists   I year              (01)  9,867 I/        (02)(03)    -0-
                 Regional   Training   Program

           Y@21-  Innovations   in   Clinic      3   years           (01)    14,500        (02)     14,500
                  Nursing: Patients, Person-                                               (03)     14,500
                  nel  and   Practices

           #22-  Coordinated Oncology Chemo-     3   years           (01)    78)000        (02)   78,000
                 therapy Program                                                           (03)   78POOO

           #23-  Pilot   Study:   Heart-Sounds   3   years           (01)    48,000        (02)   48,000
                 Screening  of   School   Children                                         (03)   48,000

           COMPONENTS  OF   FIFTH   SUPPLE-                                          Recommended
           MENTAL     APPLICATION                                    Ist Year Funding      Future  Level
           (August 1969 Council)                                           (dc.o.)_
           #19- (Revised) Physician's            3   years           (01)$183,321          (02)$169,662
                 Assistant Training Program                                                (03) 1143,   220

           COMPONENTS  OF   SIXTH   SUPPLE-
           MENTAL     AP@NICATION
           (December   1969   Council)

           #24-  Medical   Student   Operation   3   years           (01)    -0-           (02)(03)  -0-
                 of  Edgemont   Clinic

           #25-   Problem-Focused,    Group-     3   years           (01)  43,443          (02)     44,374
                 Oriented and  Cui,uL,unity@                                               (03)     45,309
                 Based Continuing Education




        NORTH CAROLINA Regional Medical Program                               RM 00006   7/70.1

        COMPONENTS 0   FIRST
        RENEWAL APPLICATION
        (March 1970 Council)                                                Recommended
                                              Approved.@      lst Year Funding     Future Level
                                            Project Period         (d.c.o.)
        #5R- Medical Library Extension       2 years          (01)   23,763        (02) 23,763
                                                                                   .(03)    -0-
        #6R- Cancer Information Service      I year           (01)   31,050        (02)(03) -0-

        COMPONENTS OF SEVENTH SUPPLE-
        MENTAL APPLICATION
        (July 1970 Council)

        #3R- Diabetic Consultation and
             Educational Services

        #26- Emphysema and Lung Disease
             Program


        *(Earmarked)
        I/ Funded from 01 unexpended balance
           Funded $12,000 from 01 unexpended    funds














                                                                          DRMP/GRB/5/11/70









                                                    NORTH CAROLINA REGIONAL MEDICAL PROGRAM
                                                PROJECT #26 -  EMPHYSEMA  AND  LUNG  DISEASE  PROGRAM


                                                                 BUDGET    COMPOSITE


                                                       CONSULTANT                                  ALTER. &
                                            PERSONNEL    SERVICES    EQUIPMENT  SUPPLIES   TRAVEL   RENOV,   OTHER    TOTAL


                         FIRST   YEAR
                           Cleveland          14,500        -0-      $  6,235     -0-     $    200   -0-      -0-     $20,935
                           Memorial
                           Hospital,
                           Shelby
                           Wilson              -0-          -0-        2,900      -0-         200  $8,000     -0-     11,100
                           Memorial
                           Hospital,
                           Wilson

                           Western   NC        2,500        -O-        3,600      -O-         200    -O-      -O-       6,300
                           S an i car iLun,
                           Asheville

                           McCain              -0-          -0-         -0-       -0-         -0-    -0-      -0-       -0-
                           Sanitarium,
                           McCain

                           Duke, Univ.,      33,665      $1,200        10,520    $  900      1,000   -0-      -0-     47,285
                           Durham

                           Pitt   Mem@       17,000         -0-        3,085       -0-        200    -0-      -0-     20,285
                           Hospital,
                           Greenville

                           N.C. Baptist      11,600         -0-        5,000       -0-        200   1,200     -0-     18,000
                           Hospital,
                           Winston-Salem                                    0    $ 900    $2,000   $9,200     -o-   $123,905
                                 TOTAL      $ 79,265     $1,200      $31,34

                         SECOND   YEAR
                           Shelby           $ 11,500     $  -0-      $  2,500    $ -0-    $    200 $   -0-    -0-   $  14,200

                           Wilson                 -0-       -0-        2,500       -0-        200      -0-    -0-         200

                           A&heville           2,500        -0-          -0-       -0-        200      -0-    -0-       2,700

                           EaCain                 -0-       -0-          -0-       -0-        -0-      -0-    -0-         -0-

                           Durham             47,031        -0-          -0-     2,000       2,000     -0-    -0-     51,031

                           Greenville         29,000        -0-          -0-       500        200      -0-    -0-     29,700

                           t4inston-Salem     32,386        -0-        3,186     1,000        200      -0-    -0-     36,772
                                 TOTAL      $122,417        -0-        $5,686    $3,500   $3,000       -0-    -0-   $134,603

                         THIRD   YEAR
                           Shelby           $   8,500    $  -0-        $ -0-     $ -0-    $    200 $   -0-  $ -0-   $   8,700
                           Wilson                 -0-       -0-          -0-       -0-        200      -0-    -0-         200
                           Asheville              -0-       -0-          -0-       -0-        200      -0-    -0-         200
                           McCain                 -0-       -0-          -0-       -0-        -0-      -0-    -0-         -0-
                           Durham             51,734        -0-          -0-     2,000       2,000     -0-    -0-     55,734
                           Greenville         29,000        -0-          -0-       500        200      -0-    -0-     29,700
                           Winston-Salem      34,330        -0-          -0-       470        200      -0-    -0-     35,000
                           Other                  -0-       -0-          -0-       -0-        -0-      -0-   5,500      5,500
                           Communities
                                 TOTAL      $123,564        -0-          -0-     $2,970   $3,000   $   -0-  $5,500  $135,034
                         TOTAL ALL          $325,246     $1,200      $37,026     $7,370   $8,000   $9,200   $5,500  $393,542
                           YEARS









                                                                   A Privileged Communication


                              S     Y OF REVIEW AND CONCLUSION OF
                                   JUNE 1970 REVIEW COMMITTEE


                           NORTH-CAROLINA REGIONAL MEDICAL PROGRAM
                                        RM 00006  7/70.1

                       FOR CONSIDERATION BY JULY.1970 ADVISORY COUNCIL


               G&neral:  The Review Committee  recommended  that  this  supplemental  opera-
                         tional application for $588,306 (d.c.o.) for three years be
               partially funded in the amount of $194 764 (01 - $89,908, 02 - $62,550
               and 03 - $42,306).


               Project #3R - Diabetic Consultation and Education Services

               Critique: The Committee noted that this  is  a  request  for  renewed  support
                           for three years of a project initially funded for two years
               and four months.  The Committee agreed with review comments prepared by
               the Continuing Education and Training Branch staff.  The development of
               this project and the evaluation summary are well described$ including
               information reviewers need and appreciate.  Planning methods of procedures
               appear sound and capably directed.  Published papers coming from the back-
               ground study are noted.  Progress, projected activities, and planned take-
               over by the North Carolina Diabetes Association are encouraging.

               Based on the statements of rationale for renewal of the project, the
               objectives for the coming three years,  plans  for  implementation  and  eval-
               uation$ it would seem that the requested expenditure would be A well
               placed investment for @S.

               Recommendation:  Approval I in the amount requested with a commendation
                                 for Dr. Luther J. K61ley  for  his  continued  contribution
                                 as director at no charge to the project.


               Project #26 - Emphysema and Lung Disease Program

                  ti ue: The Committee concurs  with  the  comments  and  recommendations  of
                           the Ad Hoc Cardiovascular  Panel.  Need,  objectives  and  proce-
               dures are clear. How8ver) there  is  some  question  about  the  justification
               for equipment budgeted for six hospitals.  There is Also some q    uestion  as
               to the ability of physicians in the  satellite  hospitals  to  operate  e  ec-
               tive respiratory care units.

               The project may be feasible with conditions,  that  (1)  budget  be  reduted$
               particularly equipment; (2) assurances  of  the  availability  of  personnel;
               and (3) need for more  information  about  proposed  training.  The  Committee









              North Carolina                     2


              believed that this proposal could best be evaluated by a site visit.

              Recommendation:  Deferral for a site visit and return to Committee.



                                  SUMMARY OF RECO@E@NDATIONS
                                         (Direct Costs)

              Project                01             02              03           Total.

              #3R Diabetic       $  89,908       $ 62,550        $ 42,306        $194,764
              Consultation &
              Educ. Services

              #26 Emphysema            -0-            -0-             -0-              -0-
              & Lung
                                 $  89,908       $ 62,550        $ 42,306        $194,764

              *(Deferred for  site  visit)






























                                                                    DRMP    7/2/70






                         DIVISION OF REGIONAL MEDICAL PROGRAMS
                      SUMMARY OF AN OPERATIONAL GRANT APPLICATION
                                 (A Privileged Communication)


         NORTH DAKOTA REGIONAL MEDICAL PROGRAM                     RM 00060  7/70.1
         University of North Dakota                                June 1970 Review Committee
         1600 University Avenue
         Grand Forks, North Dakota  58201

         Pro@ram Coordinator:  Theodore H. Harwood, M.D.

         R@e uested
         P r p@r @m
         Period             Ist Year       2nd Year      3rd Year           Total
         Direct Costs:      $191,305       $194,902      $201@257          $587,464
         Indirect Costs:       -0-            -0-           -0-               -0-

         TOTAL              $191,305       $194,902      $201,257          $587,464
         History:  The North Dakota Regional Medical Program is administered by the
                   North Dakota Medical Research Foundation and covers the state of
         North Dakota which encompasses approximately 71,000  square  miles  containing
         a population of 650,000.
         A planning grant was awarded for a two-year period, July 1, 1967 - June 30, 1969.
         The first year award was in the amount of $188,010 and the second year award
         was $192,960, decreased by an unexpended balance of $113,193  from  the  first
         year, resulting in a total award of $79,767.
         Staff assistance visits to the Region were conducted in  November  and  December
         1968. A site visit was made on June 12-13, 1969 to  review  the  North  Dakota
         RMP's initial Operational Application.
         In order to provide continuity to the program, an extension of four months
         to the planning grant with additional funds in the amount  of  $31,984,  based
         on the Region's annual level of support, was made on July 1, 1969.
         Although the North Dakota RD.IP initial application was recommended for approval
         by the Council in August 1969,due to the restriction in  funds,  an  operational
         award for the Core component only was made, effective January 1,  1970,  in  the
         amount of  $255,942.
         An amendment to the operational award was made January 23, 1970  in  the  direct
         cost amount of $314,816 to authorize the region to implement its four
         operational projects as follows:



            NORTH DAKOTA Regional Medical Program           -2-         RM 00060  7/70.1

                                 OPERATIONAL STATUS - (DCO)



            PROJECT                                                        FU
            NUMBER     IT: II IT: LL El
                                                                           $255,942
                       Core
                                                                              6,745
            1          Dial Access
            2          Training Nurses in Rehabilitation Techniques          30,489
            3          Program for Caring for Patients with Electrolite
                       Imbalance                                               9,583
            4          Coronary Care                                       - 12,057-
                       TOTAL                                                $314,816
            present A  lica-,ion:  The region has submitted five new operational projects,
                                 and they ap ear in the order of priority assigned by
                                             p
            the Regional Advisory Group.  All programs are oriented to the continuing
            education for physicians, nurses and allied health personnel.
                                                                                      Requested
            Proj. l@5-Diabetes and ut@it'On,-This project resulted from  a  request
                    from the North Dakota  L)IeLeLLc Association to the North           $33,50
            Dakota RMP, to sponsor a one-day seminar on diabetes andatherosclerosis
            in November 1968.  As a result, the region set about organizing a
            program whose objective was to study and  develop  educational  methods
            to improve the care of patients with diabetes, and of others requiring
            expert direction in therapeutic dietetics.  Advice was sought from
            Dr. Donnell Etzwiler, Director of the Diabetes Detection and Education
            Center, Minneapolis, and Dr. Edgar Haunz of Grand Forks Clinic, an
            officer of the American Diabetes Association.  Co-sponsoring the
            symposium were the North Dakota RMP, the North Dakota State Nurses
            Association, and the University of North Dakota Medical School.
            Initially, a team consisting of a physician, two nurses and a
            dietician from each local area will attend a week-long intensive
            training program at the Diabetes Detection and Education Center in
            Minneapolis.  Later this group will develop local teams, plan and
            develop informational meetings and  disseminate  information  for  pro-
            fessionals and patients.
            The North Dakota RMP will assist in the development of training
            programs for local personnel by two-day sessions covering the subject
            matter and by means of team teaching techniques.  The region will
            supervise the local programs to enable the local team to conduct
            classes on a regular schedule. North  Dakota  REP  staff  will  provide
            much of the material for the programs.





         NORTH DAI"OTA Regional Medical Program       -3-            RM 00060   7/70.1

                                                                              Requested
                                                                              First Year
         A minimum of four seminars will be conducted the first year to
         develop four teaching teams, and four in each succeeding year
         until a network is established.

         The North Dakota RMP staff will cooperate with the State School
         of Science at Wahpeton to present a series of programs through-
         out the state on diabetes and nutrition.  Eleven one-day sessions
         are planned for the first year to be held in key locations
         throughout the state, and at the North Dakota State University
         at Fargo.

         In an effort to encourage and support the Division of Continuing
         Education at the University of North Dakota in the establishment
         of courses in nutrition for food service personnel, seminars will
         be conducted for food service personnel of various institutions.
         These will be sponsored by the Division of Continuing Education
         and the Department of Home Economics at the University of North
         Dakota at Grand Forks, in cooperation with the State Department
         of Health, the North Dakota Hospital and Nursing Home Association
         and the North Dakota Dietetic Association.  Faculty of the
         Department of Home Economics will conduct the classes on the
         campus of the University of North Dakota.
         Educational needs of patients with diabetes on Indian reservations
         in North Dakota will also receive attention.  The USPHS Hospital
         on the Turtle Mountain Indian Reservation at Belcourt requested
         assistance of a nutritionist from the North Dakota RMP in teaching
         classes for patients with diabetes.  Initially, Indian women now
         working as home health aides will'be given training in dietary
         care for the diabetic patient, and this service will later be
         expanded to other reservations.
         The North Dakota RMP hopes to utilize the Human Nutrition Labora-
         tory at the University of North Dakota, slated for comp etion in
         late 1970.  This is reported to be the only facility of this kind
         in the nation.
         Methodology for evaluation consists of complete records of all
         seminars and training sessions, curriculum contents of training
         sessions for the teaching teams, national consultants, evaluation
         by staff of the North Dakota RMP, interviews, etc.
         Second Year:  $31,250                       Third Year:  $28,950
         Project #6 - Stroke Nursing Care.  This program will be based at       $28,751
                      the Neuropsychiatric Institute at St. Luke's Hospitals,
         Fargo, North Dakota.  It will be headed by a nurse to coordinate
         and administer the program in continuing medical education for
         nurses in the care of acute stroke patients and other diseases of
         the central nervous system.




        NORTH DAKOTA Regional Medical Program           -4-              RM  00060  7/70.1

                                                                                 Requeste
                                                                                 First Ye
        Nurses from hospitals and other institutions in North Dakota
        as well as adjacent parts of South Dakota, Minnesota and
        Montana will be offered the'opportunity to participate.

        The training program will be an intensive five-day plan,
        primarily of the acute stroke patient, but will. include other
        hospitalized patients.  A maximum of three courses will be
        offered each month with two to four nurses participating.

        A two-day workshop will be held semi-annually for  nurses  who  have
        participated in the training to learn  additional  techniques  and/or
        a refresher course. Instructional techniques  will  be  varied  and
        include lectures, discussion groups, the use  of  appropriate  audio-
        visual materials, and clinical practice.  Major  emphasis  will  be
        directed toward the demonstration of new'  techniques,  participation
        by the trainees in the actual care of patients,  together  with  the
        proper use of treatment facilities.
        The course content will consist of classroom teaching and supervised
        clinical training.  It will utilize the expertise of the staff of the
        Psychiatric Institute at St. Luke's Hospitals, whose  staff  has  the
        competency to carry out all phases of the program.
        Dr. Lee Christoferson, who is also the  Chairman  of  the  Regional
        Advisory Group, will coordinate the contributions  of  the  various
        members of the professional staff, assisted by  Dr.  Robert  Ivers,
        Medical Director.  Evelyn Elhard, R.N., will be the full-time
        program Director, assisted by Sister Carol  Newburger,  Director  of
        Nursing Education, North Dakota RMP. Miss Elhard  has  been  a  full-
        time member of the North Dakota RMP Core staff since March 1, 1970.
        She will be detached from the Core Staff and  reassigned  as  Program
        Director for this project.
        During the five-day intensive training course for  nurses,  an  evaluation
        of the daily course program will be made by staff members and by partici-
        pating nurses on special forms.  Approximately two months following each
        two-montli training course, appropriate evaluation measures  will  be
        followed up by staff of North Dakota RMP and the trainees.     The Director
        of Nursing Education of the Core staff will visit periodically each
        institution which has participated in this program to discuss with the
        group the effect of this training on the total spectrum of care
        provided in that institution. The Stroke  Committee  of  the  North
        Dakota RMP will review and evaluate the curriculum, methodology and
        techniques of the training course on a continuing  basis,  and  make
        recommendations for changes that might prove beneficial.
        Appended to the application are letters of interest and support from
        adjacent Regional Medical Programs.  These include the Mountain States
        RMP (Montana), Northlands, Nebraska-South Dakota (both states).
        Second Year:  $29,292                          Third  Year:   $30,422




         NORTH DAKOTA Regional Medical Program       -5-          RM 00060  7/70.1
                                                                               Requested
                                                                               First Year
         Project #7 - Respiratory Care Center. This project will be based at   $ 68,392
                    Deaconess Hospital, Grand Forks, North Dakota, and will
         provide special training for professionals and nonprofessionals in
         North Dakota in the use of special equipment and therapy for patients
         with chronic and obstructive lung diseases. The program will  emphasize
         ar'abulatory care of patients and is designed to meet the critical needs
         for improved patient care of pulmonary diseases. This porject  will
         serve a population base of a large rural area of North Dakota and
         Minnesota where there are many small communities with very small hospitals
         or nursing home facilities available for basic hospital and nursing home
         care. Twenty-two hospitals in the area already cooperate with  Deaconess
         for i-n-service training of personnel, and there are fourteen nursing
         homes in this immediate area.
         During the past two years a Community Health Planning Committee has
         developed in Grand Forks and has made progress toward maximizing the
         facilities for personnel now available.  This committee is made up of
         community representatives, plus individuals from the eight different health
         care organizations including hospitals, the University Medical School,
         the Rehabilitation Center, the Mental Health Center and the nursing homes,
         all of which have entered into a comprehensive health planning program study
         to develop the best possible program for the area.
         The Community Health Planning Committee retained the firm of Herman
         Smith Associates, Hospital Consultants, and measurable progress  is
         already noted.  This committee is working toward the development of a
         coordinated body to assist in improved communications and  decision
         making between the two hospitals, the Grand Forks Clinic and  other
         physicians, the University Medical School and related services, as  well
         as the Mental Health Center and the nursing homes.
         The education and training of health care personnel is viewed as the
         primary function of the Respiratory Care Center which will be established
         through this program. Courses in didacticand practical  instruction  of
         inhalation therapy will be offered, and attention will be given to  the
         development of programs for inhalation therapy Assistants.  This will in
         time provide the meansfor establishing an accredited school for  inhala-
         tion therapy technicians at the Respiratory Care Center.  Center personnel
         will provide advice and assistance to other institutions wishing to
         establish their own programs.  Other medical and scientific personnel
         in the area will be encouraged to participate in the education  program.
         Another primary function of the Respiratory Care Center will provide
         a definitive diagnosis of the type of disease present,  the  degree
         of its severity and the likely prognosis in each case.  A full




         '@ORTH DAKOTA Regional Medical Program         -6-               RM 00060  7/70.1
                                                                                Requested
                                                                                First Yea
         assessment of the patient's status will be presented to the
         referring physician. Also included is a patient  education  program
         designed to inform And educate the patient in the nature of his
         lung disease, its cause, what it means to him for the future,  etc.
         The patient's status will be supervised on a continuing basis
         -Following his initial evaluation at the Care Center.  This will
         involve a communications system utilizing several levels of  health
         Personnel, e.g.,a Program Coordinator at the Care Center, the
         patient's family physician, a home visiting service, etc. -Return
         visits to the Care Center at regular intervals for complete re-
         evaluation and necessary modification of the patient's  therapeutic
         program will be encouraged.  The Center will provide in-hospital
         care as well as ambulatory.  The basic purpose, however, will be
         to provide services which will lessen the need for hospital
         admissions, insofar as possible, by preventive care at the Center
         and in the home.


         I
         .@ursing personnel of the county and city nursing units will be
         involved in the training sessions in order to participate  actively
         ;-n the patient education program and in the visits to those who are
         ,iomebound.
         Tile proposed center will have the following staff initially:  a
         ,@l,edical Director, Dr. Harold W. Evans (part"time), a Program
         Director, Inhalation Therapist of Deaconess Hospital, fulltime,
         an Associate Director, Dr. T. A. Gallantly (part-time),a Patient
         Service Coordinator and a secretary-typist to be selected.
         @IP support is requested for the organization and initial operation
         of the Respiratory Care Center only for those persons who will have
         administrative and teaching responsibility, and for a limited
         amount of additional equipment.  The Deaconess Hospital expects
         to continue this program as a hospital service to the community
         !:Ollowing the expiration of any grant received.
         Second Year:  $69,559                      Third Year:  $72,634
         Project #8 - Physician Educatio Pro ram.  This  program  was  developed  $42,530
                      under the auspices of the Education Committee which
         functions as a coordinating agency for the State  Medical  Association,
         other state associations and agencies related to health care,  and  the
         educational institutions of the state.
         It was concluded as a result of the response to a questionnaire
         submitted to practicing physicians in general practice  or  partial
         specialty, that there exists in North Dakota a real desire  for  an
         interchange of information with other physicians, particularly with
         specialists. It was also evident that there is  available  a  large
         number of well-trained individuals in specialty practice throughout
         the state, who are willing and able to participate in such  a  program.




           H DAKOTA Regional Medical Program            -7-              RM 00060  7/70.1
           ital administrators also indicated that their  facilities  were
           lable for teaching programs when developed.
         It is proposed to develop a cadrE: of North Dakota specialists who
         are willing to become members of a visiting physician team to conduct
         educational conferences in interest of improving patient care.
         The ND/RMP will initially provide the staffing and direction for this
         program, with the understanding that the Department of Community
         Medicine at U.N.D. will add to their faculty a Director for Continuing
         Education.  As soon as practical he will take over full responsibility
         for the development and further operation of the program.
         Methodology will vary, but initially, it will take the form of informal
         discussion with groups or among individuals, as may be mutually satis-
         factory. The conference trips will be rotated among  participating
         -visiting physicians, but a specific specialist may be requested.
         Students at the School of Medicine may be invited to accompany the
         visiting physician as a part of their training and orientation.
         The third component of this program is designed to increase library
         services for the health professions. It will expand the  resources
         at the Chester Fritz Library at the U.N.D.  A medical librarian will
         e added and a system will be initiated for physicians who are unable
         0 come to the campus to request materials.  As new systems for the
         etrieval of library information are developed, they will be added.
         Second Year:  $45,571                    Third Year:  $49,074
                                                                                 Requested
                                                                                 First Year
         Project @t9 - Cancer Registry,  This program was developed under the    $18,126
                     auspices of the Cancer Committee of the ND/MP, and will
         build on the experience of an existing registry at the Quain  and
         Ramstead Clinic at Bismarck, North Dakota.
         The initial work began in April 1969 as a pilot study under the
         direction of Conrad Dietz, Director of Computer Services at the U.N.D.,
         and a part-time staff member of the ND/RMP.  DRMPS consultation has
         also been provided by the Operations Research and Systems  Branch.
         The Cancer Committee recommended that Dr. Pablo Ramos of the Quain
         and Ramstead Clinic be sent to the computerized Tumor Registry Workshop
         in Salt Lake City on May 28-29, 1969.  Subsequently, data from the
         registry at Bismarck was transferred to the U.N.D. Computer Center, a
         system of report forms was developed to provide specific data  for
         physicians, hospitals, and others, and other activities preparatory to
         centralizing the registry were accomplished.
         The computer function, which will now become statewide, will assume some
         of the reporting functions of the local registries, which exist in all
         the larger hospitals and some of the smaller ones.  The local registries
         will now need to keep only one file of each cancer patient.






                                                                                   170.
         NORTH DAKOTA Regional Medical Program                          RM 000 0  7

                                                           'etary for the
         This project requests support for a Registry secr
         regional registry, and a series of workshops of one and one-half
         days duration for registry secretaries throughout the region.  The
         regional secretary will attend a four-week  training workshop at
         the San Francisco Medical Center, and will later be designated as
         the -Instructor for the ND/RMP workshops.
         Evaluation for this project will be the joint responsibility of the
         regional staff and the U.N.D. Computer Center.
         Second Year:  @19,230                       Third Year:  $20,177
































                                                                     4/28/70




                                                                                       NORTH DAKOTA
                                                                                       ltllf 00060  7/70.1.



               STAT,'F OBSEE,VATION



                                CaLicc,  P,.

               This project has Hot                   in its dLsiE,,ri the t@ic,@,ins for              its
               services to the three Iridiz-An. llospit4i].,, in the                  In r,@l@Ps st@iff
               di.,@ctissioi--is i,@itli     of the            of Iiiciiin IIL@-al,tli, tlic@! 13ureati in(.Ii.E,
               catc,@(I i@'t.1.1i,Lignes,@@ to pnrtici.pnte, and                             in l@rio@-iins
               wli,i.L Ref,,ional. llodicil            li6,vc! furxdc@l of@t@,oi,rig Canct(@r Registries.
               This itiforinptic)ii hc,.&@, been              by R@I.PE) for c!iE:@tribi.iti.on to II'L@3
               Hospl.t,ils, as i,,ell as offers of techr)-,t.cil Hand oti-ic@i,




































                                                                                          6/4/70





                                                            A  Privileged  Communication
        .4




                                  S@RY OF REVIEW AND CONCLUSION OF
                                     JUIQE 1970 REVIEW COi4l@iITTEE


                               NORTH DAKOTA REGIONAL FIEDICAL PROGRAM
                                            RM 00060 7/70.1

                          FOR CONSIDERATION BY JnY 1970 ADVISORY COUNCIL


             General:  In reviewing the Regionis first operational supplement composed
                       of five pro ects requesting @191,305, the  Review  Committee  noted
                                   i
             that the order in which the,projects appear indicates the order of priority
            ,assigned by the RAG. The Committee also  noted  that  the  region-continues
             its efforts in continuing education of physicians, nurses and allied health
             personnel.  Two projects received a recommendation of approval with additional
             funds in the amount of $51,632.  Three projects received the recommendation
             that they be returned for revision to incorporate certain conditions.  Project
             #7 was negatively received and no funds recommended.

             Project l@5 - Diabetes and Nutrition

                        The consensus was.that the project has demonstrated the feasibility
                        of an approach to the nutritional management of  persons  with  dia-
             bet6s and other chronic diseases. It has been  carefully  planned  and  the
             demand seems to have been well established.   The method of  procedure  would
             seem to be adequate for this region and speaks %7e].l of the harmonious rel.8tioti-
             ship with the North Dakota Dietetic Association.  The  funding  requested  is
             very modest, and it is expected that the effort will go.a long way to encourage
             continuing and closer relationships with the Division of Continuing E ucatioli
             at the University of North Dakota as well. as assistance in  the  establishment
             of the new Human Nutrition Laboratory.

             Recommendation: Approval I    additional funds recommended.

                    01-Year                      02-Year                 03-Year
                   $33,506                      $31,250                 $28-, F3(-)-


             Project ft'6 - Stroke Nursing Care
             Eri.tiot@e:  This application was believed to be poorly designed.  It is
                        lacking in a statement about criteria for  selection  of  learners
             whether Rlls or LPkls. There is no plan for-assessin(y neurologic function  -
             during or after come., nor any indication that a plan for care is being
             developed. The competency of the nurse faculty is  limited  to  intensive  care
             unit practice and by minimal educational practice for this assignment (includ--i,-c@g
             the classroom instruction and more importantly the circuit riding).

             The impressions gleaned from the physicians who will participate in  the  pro.-
             gram appear to be largel,y general and without documentation.   Neither  is
             there an expression of interest or need by nurses.   The project on  the  whole





             seems to be teacher oriented with broadly stated objectives  which  are  felt
             to be quite immeasurable, unclear, and impossible for achievement.
             The proposal to put on 36 one-weeic courses per year with @@@eeks "in  between"
             for circuit riding indicates that the project directors have no idea of
             what is involved in supportive circuit riding, or  in  activities  related  to
             course conduct.

             Although there are several schools of nursing (hospl'til  diploma  and  collece
             based) in the region, there is no mention of their involvement.  Their
             faculties might be very good local reinforcement, and  should  be  invited  to
             participate.
             The proposed evaluation was thought to be generally meaningless in    its approach.
             This is unfortunate in that this lind of project lends itself very    well to an
             adequate evaluation design.  This aspect will need strengthening.     The
             budget seems unrealistic and no mention is made of  plans  for  phasing  out.
             The reviewers noted that the need for -the project is obviously urgent) but  n
             its present form, it contains   so many flaws that it is  unacceptable  without
             some serious restructuring.
             Recommendation:  Non-@Approva). II   return for revision required v,7hich should
                               reflect the following conditions: (1)  Delineation  of  the
             curriculum; (2) Transmission to. the region of the comments of the Continuing
             Education Pan8l; (3) Statement of the relationship of this project to
             Project-i@2 - Tral.ninR Nui--@(,-@- in Rehabilitation Te  Pf,--are they mutually
             supportive?


             Project lr'7 - Lc-
                             -@ir        re Center
             @ri@,je: The reviewers found the method  proposed  for  organizing  an  editca-
                         tional program such as this to be unclear itid ,,somewhat short
             shrift.  The functions of some of the project staff, such as the Patient
             Service Coordinator, are not given.

             The statement of need is based upon impressionistic data, with no -firm
             beginning point. The objectives are not  well  defined  and  although  related
             to patient care, are not measurable in the form in  which  they  appear.  T  e
             application does riot indicate how the improved care of'patientq will be
             ascertained except that patients will be treated in the center.

             The project appears feasible and could probably be carried out,    but more
             information is essential for an adequate  appraisal.  There  is  no  descrip-
             ti6n of the medical school or other educational personnel as project resources.
             It is assumed that the project personnel possess  all  the  expertise  require
             for this undertaking.

             The concept of evaluation is also traditional. It  does  not  provide  for  a
             measurement of learning, or measurement  of  chanae  in  respiratory  function
                                                               t,
             as a result of treatment in the unit.  There is no plan to assess the
             dissemination of the technique, to physicians, or to  other  institutions,  as
    0                                        .



              NORTIT DAYOTA P@IIP                     3-                 ilal 00060 7/70.1

              a result'of the establishment of this center.  '.rrie project would probably
              benefit greatly from the services of an evaluation consultant.  In the
              opinion of the reviewers some addition to the budget will be necessary in
              order to carry out an adequate evaluation.
              The salaries of the physicians    the project staff appear high when compared
                                                                     however, seem lower
              to urban standards; those of the nurse atid,secretary,
              than metropolitan areas.
              Another question was raised concerning how the two individuals, each devoting
              one-third of his time to the project would oth ernqise occupy their time.  The
              activities described in the project would not appear to require two individuals
              with this percentage of effort.
              The project overall was felt to be fli.riisy with no certainty of attaining the
              aims it sets forth.  l@t is also deficient in its regionalization aspects.
              In such a low density popiil.,-.ition, the reviewers thought it might be more
              useful to send its trainees to other regions (Northiands), with perhaps
              additional refresher training.
              Recommendation:  Non-Approval I - no D@IP funds

              Project @PS - A Comi)rehensive Physician Educati.on.Ti-o@rqm
                         The reviewers felt that the educational plan was vague and
                         did not appear to have made use of the experience of other programs,
              such is the Kansas Circuit Tour Program, in developing the format and design
              of the program.  There seemed to be more concern with the form of the applica..
              tion than with its substance.  The faculty is probably competent for the
              rol:es they will be given, but it was questioned whether the desire to parti,ci-
              pate, and the possession of a specialty certificate, qualifies a teacher.
              The need for the project seems to be based on the interest of the physicians,
              but fails to emphasize the categorical gool-s of IUIP.  The physicians were
              contacted by means of a questionnaire with 41 responding.  The total. number
              sent out is unknown.
              Most of the ojectiv,-s, although questioned for clarity and their inability
              to measure impact, @,;ere fel't to.,.be operational rather than behavioral in
              their end results.   The approach is reasonable, but somewhat stereotyped.
              The rather disparate groupings of partici. itit.s do riot lend themselves to a
                                                        p
              good design for a comprehensive training program.  Furtl@ier, there is little
              evidence that this kind of c@ducation really "sheiks" anyway.
              There seems to be very littl,(--- evidence that the authors of the project
              received consultative assistance from the Uni.ver@@-i-ty of I\Iorth I)akota, even
                                                    '@ le iiic
              though the region plains to usc-. av@iila,,) -dic,.il specialists as instructors.
              Rc-,coiilmlc-,i,qati-o,n: I\Ion-Al)l)rov,3.3 I - the application v:,is considered totally
                               inacl,eqLi,).te in its present form. 'J.@)c recommendation carries
              the             to the I!egioti that -;I-iould the      be resubmitted, the
              applicant should       help in its total redc@sj-.gn.




                 NORTH DAKOTA RMP                                -4-                     iui  00060  7/70.  I


                 Project #9 - Cancer

                         tie:  This 'program was developed with the assistance and consultation
                  r-i Li Li-
                               of   RIT.PS   staff.  The reviewers felt that the.project in general
                 is a good    one  and  fil,l.s  a  very,@eal  tiec@d   in   the   Regi'on.   The resources are
                 identified and the reviewers felt @'hbt it is laudable that the North Dakota
                 R14P is looking into the cancer program in the state of North Dakota.

                 Vlhile the Committee unanimously endorsed this project,  there were some
                 reservations.   There is no indication that the services of the Cancer Registry
                 will be extended to the two Indian hospitals in the region.   It was noted
                 that these are the sources of medical treatment and care for Indians living
                 on the three reservations in the state.   The application does not indicate
                 any   awareness   on   the   part   of   physicians   of   the   high   cervical   cancer   rate
                 in   the   Indian   population.   There   does   seem   to   be   a   full   complement   of
                 capable physicians available for the treatment of patients with cancer, but
                 no   indication   that   these   are   reference   points   for   the   Indian    popillit-ioll.

                 There was some doubt expressed as to the ability of the region to continue,
                 an effective registry within such a modest budget.   It was suggested that
                 with the incorporation of the suggestions of the reviewers, a more realistic
                 budget   could   be   negotiated   for   the   second   and   third   years   of    support.

                 The   Review   Committee   also   questioned   the   lack   of   a   stated    interface    with
                 the   Intermountain   RI@IP   which   has   an   ongoing   automated   cancer    registry    for
                 all of the llotintain States.         I'lic- project staff of Intermountain were
                 consulted by              in organizing a registry for                   and on(-, would
                 expect some plan for data from North Dakota would continue.

                 Rc@corr@mcnd,gtjons: Approval I - the conditions to this approval are:  (1)
                                       The   region   must   attempt   incorporate   in    the    registry    the
                 Indian   Health   Service   data   through   the   exi.stin(,   Indian   hospitals    in    this
                 region for a broad comprehensive cancer registry proc,,ram;  (2)  the North
                 Dakota [U.IP should sLib,,Pit annual reports relative to cancer in North Dakota
                 including   all   of   its   citizens   and   (3)   additional   funds   will   be   added   for
                 the continuation y(@,sr,@vi-a an flopen end" negotiable award for this project,
                 desi,gned for,all- its citizens.

                                  01-Ye,)r                         02-Year                      03-Year
                                  Ti,-8 -1-2-6"                  to    be    negotiated        to be negotiated



                                               OF R'J.,"COIsl.'II,,N'Dl@TTONS


                                                O)-                   02                   03

                 #5                          $33,50()              $31,'4'50            $28,950
                 i(I 6                          0                     0                    0
                 ,'i 7                          0                     0                    0
                                                0                     0                    0
                   9                         $19,126             to   be               to  be ne.@
                           Total             $51,632               $31,250              $28,950


                                                                                        I?J.lps/G@",B/7/10/70






     i














            0                                                              0                                                              0





                                                                 A  Privileged   Communication



                                           SPECIAL ACTION


                            NORTHEASTERN OHIO REGIONAL IE'@IDICAI., PROGRAM
                                          PM 00064  7/70.1


                         FOR CONSIDERATION BY JULY"1'97,QADVISOIIY COUNCIL



                   raly,  oordinator-.  Barry Decker, M.D.

              This is a request for special action by Council to consider a re-vision
              of a project disapproved by  the  March  1970  Council.  During  the  May
              negotiation meeting for their first operational grant, the RAG chairman,
              the Case-Western Reserve School  of  Medicine  Dean  and  the  Coordinator
              expressed such concern about the  effects  of  the  disapproval  for  this
              activity on @E? development that M'S staff agreed to consider special
              handling of a  revised  project  proposal.  The  revised  application  was
              received too late for Committee consideration and review.

              Requested          lst Year       2nd Year       3rd Year        Total

              Direct costs       $48,233         $50,145        $26,076        $124,454
              Indirect costs        3,823          4,014          2,108           9,945


              Total              $52,056         $54,159        $28,184        $134,399

              Back rounds:' The  initial tliree-year operational- grant application for
                            $3,623,467 (d.c.o.) was reviewed by Council in March 1970.
              Council concurred with the Review Committee. and the  site  visitors  -i-n
              their recommendation that  this  Region  be  awarded  operational  status'
              Council recommended partial funding  at  $2,395,104  for  core  and  four  proj-
              ects. Six other  proposals  were  disapproved,  two  of  which  were  considered
              inappropriate for Pd,!P support.  The  Region  had  demonstrated  capable  lead-
              ershi-p in developing  cooperative  arrangements  throughout  the  area,  estab-
              lished data collection mechanisms and a priority system, and recognized
              the need foi- strengthening evaluation processes.

              Prese-cit.-. ADpl.i.cEiti-on.-  This is f--i revision of Project #7   Requested
                                      wlai@li received a non-approval II    Ti r --
              action by Council in March 1970.  Strong feelings about           $48,233
              the importance of this  project  were  expressed  by  the
              NEOPJ,,IP representatives, includiiao the chairmen of the RAG  and  Board
              during the negotiation meeting, May 1970.  It was agreed that a specific
              summary of its deficiencies would be submitted to NEOITMP to a]-low the
              local resources tiic- opportunity to improve and resubmit the project for
              appeal to the  next  meeting  of  Council. notice the reason for t e request
              for special action.

              In, considering the original project, the rcivi-e@;c,.i,.@s were most i.ilipre,lso-d
              with the Project D-ii-ector's interest ill prorr@fl-)tj.i-.,,, gyeq-.tcr corlirillinit
                                                                                      y








              Northeastern Ohio PM                  2 -             Rm 00064  7/70.1


             .efforts toward rehabilitating stroke patients.  His enthusiasm as an
              orthopedist in  private  practice  and  the  interest  of  the  Crippled  Child-
              rents Center in expanding its basic mission to include adults, were
              considered  strong  assets  for  the  potential  of  the  program.  However,  the
              objectives and procedures were quite diffuse and it was difficult to
              determine what  the  project  would  actually  contribute  to  medical  care  in
              this area.  A major concern was that the project seems to indicate a
              primary focus  on  primary  care.  Other  essential  aspects  of  a  RMP  demon-
              stration,  e.g.,  training,  continuing  education,  linkages   between   other
              hospitals and communities, were not adequately explained.
              As proposed by  the  Lake  County  Society  for  Crippled  Children  and  Adults,
              the goal of this revised  project  is  to  develop  and  apply  the  concept  of
              comprehensive and  more  efficient  care  for  stroke  patients  in  a  sub-re-ion
              (out of Cleveland)  of  NEO@IP  where  such  care  is  not  presently  available.
              RMP funds are requested to develop the necessary training, continuing
              education,  communication  and  agency  cooperation  and   necessary   linkages
              to  sustain  a  comprehensive  stroke  care  program  in  three  counties.  The
              objectives include establishment of a comprehensive ambulatory stroke
              care  program,  emphasizing  early  rehabilitation  and  continuity  of  care  in
              the hospital-  and  after  discharge;  demonstration  to  increase  public  and
              medical  awareness  of  the  benefits  of  comprehensive  stroke   rehabilitation,
              including  economic  feasibility;  and  to  establish  a  replicable  model  of
              comprehensive  ambulatory  stroke  care  in  a  non-liospital  setting.  A  stroke
              rehabilitation. team,  under  the  supervision  of  the  Project  Director,  will
              work closely with  the  attending  physician  in  determining  @course  of  treat-
              meiit. The attending physicians,  in  charge  of  the  patient  at  all,  times,
              will be encouraged  to  participate  as  part  of  a  team  including  periodic
              case  handling  reviews.  The  Project  Director,  the   Consulting   Neurologist
              and a Nurse  Coordinator  will  introduce  the  program  through  a  series  of
              meetings and contacts with the Pi,--dical- community.    Follo@qtip by mail  and
              personal contact is planned.  Evaluation x-7il.1 be based on comparative
              studies relative to the  impact  of  the  project  in  terms  of  patient  manage-
              mc-n.t and community response.   An  annual  caseload  of  approximately  85  is
                 L 4
              an .,(,jpated and is the basis of the,  support  requested  from  @f-P.  Efforts
              are to be made from  the  beginning  to  place  the  program  on  a  self-support-
              ing basis by the end of the thi-rd year.
              The Reuional Coordinator has communicated with R1,113S staff about this proj-
              ect and its relationship to the whole NEOP@IP.      He  indicated  that   there
              is an imperative need for credibilit-y of P@@IP in the area to  b  -0  served  by
              this  project.  He  further  stated  that  the  project  represents  an  activity
              outside of  Cleveland  with  a  sincere  attempt  to  provide  better  coordinated
              care of stroke patients.     A successful- demonstration  may  serve  as  a  model
              for another similar area in NEOrJIl-'.   The C,oordi.nitor  scatod  that  approval
              of the project i-s extremely important to regionaliziti.oia in I\IEOI-II'IP.

              Second Year:  $50,1/i5                   Third Year:  $26,076






                       Northeastern       Ohio        P@'jj'                       3                               P,@l 0006/i      7/70.1@


                                                           REVIE@,,T AND  FU      DING IIIS'I-'ORY


                                                                                  COSTS

                       I s t Y c a                                 1/l/68  -  6/30/69  (1-8 iiio.)                             $267 9 11
                       (Noveiiiber  1967  Council.)

                       2nd Year Planning                           7/]-/69  -  6/30/70                                    1/  $462,663

                               The  02  a7v7ard  incl-uded  funds  for  three                   feasibility  studies

                               (diabetes      training,      library      and      development      of       a       laser       unit
                               for       line       of       sight       i.ntra-liospital       television        transiaissi.oli).

                       Initial                  i@ia@p                      -i
                                                           @El-'Lca,,,:ioT
                       (Site Visited  February  1970)
                       (14arch  1970  Council)

                                                                                Approved                                                  ,k-pproved
                                                                            Lro-@C@peri-od                    Funded                  Future Leve-
                                                                            7/l/70-6/30/73
                       Core                                                 2    years,     9     To.    2/   (01)        $481,424        (02)         $586,910
                                                                                                                                        (03)            629,735
                       #1  -   Hospital-             Library
                               Consulting  Services                         3 years                            (01)           24,11-2   @\02)       24,11@2
                                                                                                                                        (03)        24,11-2
                       #2.-    Northeastern Ohio
                               Regional        Prograin        for
                               Continuing                Education          3 years                            (01)            79,844   (02)        70,358
                               of      Nurses      in       Coronary                                                                    (03)        79,84i'@
                               C a r c-,


                       #3      Pheui-,iatic       Fever       Pre-
                               ventior@.,.    Procrair@    by    a          3 years                            (01)           104,807   (02)            104,807
                                                  C,
                               Sti7eptococcal                Culture                                                                    (03)        52,496


                       #4      Orgafl@LzatioD.           for
                               lJriiveysity  Coopc@rat--ic)i@i,                App-i-cvc,,(l  but  NECI.I@'L,"I)  el-r2cUecl  t@li.c.,  option  of
                               -11,1  Fic,-al.th   (OUfC-fi)                          re-allocitii-t-           funds    to    li'3

                       1/5     Continuing      IT.IIuca'@--io-.@i.                                       Non--Approval           II
                               for Physical  i-TierapisL,@

                       #6      T(@lc@-visc@e,                                                            Non--Api.)i-(.)\ril    1.1
                               @ic@d.i'-cal  E(-Ii-icatio-f-i   ili@o@lra-,ii


                          7    A





              Northeastern Ol,j-o Pl@-P              4                  RM 00064   7/70.1


                    Dial Access                               Non--Appi-oval II

                    Summer Workshop in                        Non-a.pproval- I
                    Career Development

              #10    Medical Tax-i- Service                   Non-Approval I
                     for Residents of
                     Rural Geau-a County

               TOT,AL                                  (01) $690,187      (02) $786,187
                                                                          (03) $786,187

               1/ Includes Carryover $31,086

               2/  02 planning year was extended to Septeytiber 3C), 1970 to allow NEOP@IP
                   to expend the estimated unexpended funds (approximately $96,000)
                   allowing PI.IPS to modify 01 operational funds by that amount ($786,187
                   miiius $96,000   $690,187)












                                                              R@IP 7/10/70

















            0                                                              0                                                              0




                                        L%ULLVO











































































            0                                                            0                                                          0






                                                                                       A       Privil.c-@F.C@d        Communication


                                                                   SPECIAL ACT]-OIZ


                                                   NORi'll-f.@,k',,@,DS  REGIOI\!Al, MEDICAL PROGr@Al,l
                                                                       Ml 00021

                                    Diabetes  j@@L,,,"ection  a)-.id Edtic,-ttioii-Ccnter,  Pro  ect  #18

                                    Emergency      interim      support      for      the       Diabetes       Detection       and
                                    Education      Center      in      Minneapolis.      It      is      requested      that      the
                                    NRI,T     be     authorized      to      reallocate      unexpended      funds      from      the
                   01- operational  grant year to support  this  operational. project  entitled
                   "Diabetes  Regional  Center Educational Proci-@,ti,,i"  in the amount  of
                   $81,621.         This     would     provide     interim     financing     for      the      Center      for      the
                   remainder        of    the    Noi--tl-ilands     RlfP     02     budget     period,     ending     F'ebruary     28,
                   1971.       The Region. proposes  to submit  to  RITI-'S -a project proposal
                   requesting     support     for     the     program,     when     it      submits      its      next      applica-.
                   ti.oi-i.

                   @'Ll@.,R,.rc)u-nd-:    The    l,ortblaii(is    Rc-Fio@'tal    Medical-    Prog]7aiiis     i-7as     Iwarcled
                                       $1,624,599     for     the     02     operatioi-iil     year      starting      March      I-,
                                       1-970.      This  included  $279,238 of  carry-over  funds  from the
                   01-  year.    The Region has  an  additional  $90,000 of  carry--ove-,r  from
                   which    it    is    requesting    the    $81.,621     direct     cost     to     support     the     Cc,-i.-Itc@r
                   for  the period Jily  1,  1970  through  I.lebriiary  28,  1-971-.                           RM.PS   st:af    f
                   believes      this      activity      is      meritorious      of      support.       The       delegation       y
                   the     'Rotational     Advisory     Council     to     staff     for     approval     of      requests      for
                   expansion of  approved  activities  or  initiation  of  lc'civi-ties  ancillary
                   to Rc,,@!,ional Medical Programs  is  limited  to  $50,000.                             Therefore,           the
                   Nc@rt,'ilands      Pegioiial      Medical      Program      request      for      $81,621       i,@,,referrc-,cl
                   to  tfic @,'@ition@.il Advisory  Council  for special-  action.

                   The Diabetes  Detect!-on  and Education  Center  in @li-3.-ii-icapojis axis
                   established    in    1967    u-.ldc,,2:    a    grant    from    Coi-,I-ciluii@Lty    Ileal.tll     Services
                   Di.visio-P..      The basic  support  for  this  center cypi-recl                            June      --i-970.
                   The  Center str@3sse.-,  comprehensive  care  for  diabetics,  Health  care
                   t e an           Optimum      delivery      of      health      care      services,      secondary       T,)revci-i-
                   ti-ve                    and  a-.il)ul-atnry  out  of 1,@o@,pi-tal  care.  The
                                               Program has tN-70  @)-i-0-       IE' C 'C o, f U'- I CIC!CL by the        l@liicl-)
                   a3-c@ based  at  trie Diabetes                               -,iid l@dij(--Lill-ioi-i             O@@(-@   of    the
                                           C(.,@,-ttcr)  was  fLill@cd               I-,    19L"g,    Crlcf--U-tij-izes     the
                                 i)-r!)-sc)ni@el  to                       li'l    col@fiici,jnity    hospitals     in     diabetic
                                     -,rc)grcr,,,s  for                            tlir-c.--yc,,-tr               plan        will
                                                                                             for                  patients        i@t
                                              cc,,,  turiity                                        throughout      Ill.ni-lesot@,@:...
                   The other Project @,71,iC@l 110@S                       fii).,Jed  by  the              (Project      Yi'-15
                                                                                                                       by      the
                                             at  the






                                                                                    r@L-1 00021
              SPECIP@L 1,@CTIO'  14ortlil-arids I'ml-'      ..2-


              training and continuing edtjcati   on for dieticians incl nutritionists
              throughout IIir)ncsota,   These ti-7o ol)erat!Lol:l@"I projects represent one,--
              fifth of the active projects in Nldil.l.    Since both of these projects
              -are based at the Diabetes Center, they will have. to be discontinued
              if the Center is fo;-cecl. to close because of lEcIc of su.j.)port.  Tti--
              Nortli Dakoti R(-,giorial Mc@dical ]3rogram ilso has an operational
              proposal under revi@.,7 i,7hicli is also dependent upoi-.i the Diabetes
              Center.   It is entitled "An Educational Pi.-ogrct-,-ii foi. the Nutriti.on@-1
              Man.ageni.arit of Persons x,7itli Diabetes @nc.L other Chronic Dise-ase@,,."

























                                                                         DRI,'@P/CP:@B
                                                                         7/9/70

















           0                                                              0                                                              0










                                     l@l,:(;TONAI, MI@;I)f(;Al, I'l@()(;RAMS ':I,IRVI(,'I@'
                                   I)IVI@ION Of@' f@F(;IONAI, Ml,',T)ICAI, I-)ROGRA14@',
                      '@tIMtIAI@Y Ol,' A Sl.!I'I'I,EMI@"NI'Al, 0111@"f@A'I'IONAL (;RA@41' A.PPI,I.CA'ITON
                                       (A Privi.l.eged Communication)

              NORI'IIWI@'STI,'I@N OHIO REGIONAL NIED.rCA], PROG@L      RM 00063 7/70.1
              2313  Madison   Avenue                                   June 1970 Review Comn)ittee
              Toledo, Ohio 43624

              Program Coordinator:  C. Robert l'ittle, Jr., @I.D.

              Requested            Ist Yr.       2nd Yr.       3rd Yr.          TOTAL

              I)irect Costs        $180,971      $161,831      $167,789          $510,591@
              Indirect Costs         45,770        47,799         49,587          143,156




                                   $226,741      $209,630      $217,376          $653,747

              History: An initial  planning  grant  of  $274,450  (d.c.)  was  awarded  to  the
                         Northwestern Ohio Regional Medical Program beginning January 1, 1968.
              'I'lie @econd-year planning award of $271,137 (d.c.) was supplemented by
              $141,137 and  extended  through  June  30,  1970.  A  preoperational  site  visit
              was conducted during April 1969.  The present annualized level for Core support
              i-s $335,200, direct costs only, while the Region currently has $490,502
              allocated  to  six  operational  projects  (see  History  Supplement  for.breakout
              of this total) for the first-year operational period - July 1, 1969 through
              .June 30, 1970.

              According to the application, the priorities established during the planning
              period were to include:  1) continuing medical education; 2) improved
              rehabilitative care;  and  3)  better  and  more  prompt  diagnostic  methods.  To
              accomplish this, the  Region  envisions  its  primary  goal  as  being  provision
              for the continuing  education  needs  of  the  practicing  physician,  nurse  and
              -allied health personnel.

              I)ttring the February/March 1970 review  cycle,  the  Region  submitted  an
              application for expanded Core renewal Plus requests for four new operational
              projects. ]'he Council  recommended  that  the  Core  components  be  renewed  for
              one year at the current level of support ($335,200); and further recommended
              that a site visit be made to the Region to  determine  wl)e@tlier  the  $tl6,91z*
              increase requested for  Core  support  is  justified;  to  determine  the  amount
              of support for Core in future years; and to review the three proposals
              (one proposal. in stroke and two in continuing education) which were a  p,,'.-Il-t
              of the November 1969 supplemental application.  One proposal in the
              November 1969 application  (#12  -  Emergency  Medical  Care)  was  considered  to
              be inappropriate for RMP funding.  In addition, the reviewers believed that
              the site visit team should study the entire operational structure of the
              Region, including the total regional plan, identification of needs, assess-
              ment of objectives and  priorities.  The  site  visit  is  scheduled  for  May  21
              and ,I;@iy 22. A report of the site visit  team  will  be  available  during  the
              June/Jtily review cycle.






          NORI'IIWESI'ERN 01110 Regional Medical Program       - 2 -       RM  00063   7/70.1

                                                                                    Requested
                                                                                   First Year
          Present Application:  This    application requests support for
                                  two projects, which are revisions of
          proposals reviewed and not approved during the November/December 1969
          review cycle.  Direct costs only are noted in the following project
          summaries.

          Project #16 - A Program in Continuing Medical Education for                  '?690825
                         Physicians in Northwestern Ohio (Medical College
          of Ohio at Toledo, Northwestern Ohio Institute for Continui@
          Medical  Education).  This  proposal  was  originally  reviewed   during
          the  November/December  1969  review  cycle  and  was  disapproved.  The
          reviewers believed that the objectives of the proposal were too
          generalized and seemed to lack any continuous educational effort or
          reinforcement of the knowledge disseminated.  The evaluation procedures
          appeared to lack a defined focus and there is no indication as to the
          staffing provisions for evaluation.  The initial proposal appeared to
          be nothing more than an equipment purchasing request with no allotment
          for service in the future years, and without a sufficient number of
          adequately trained personnel to transport and maintain the equipment.

          This revised project proposes to provide for continuing medical education
          of practicing physicians in Northwestern Ohio by developing a program
          of regional conferences and clinical programs.  It is proposed that one
          regional conference will be held each month of the academic year
          in each of the five subregions,at different hospital locations.

          The subject matter of the regional conference will be supervised       and
          coordinated by the County Continuing Education Coordinator.  The       Hospital
          Chief of Staff or the hospital's Education Committee will be responsible
          for the planning of the conferences to be held in their hospital.  Specialists
          from the faculty of the Medical College or from outside the subregion
          will attend the appropriate conference and will act as principal discussants.

          I'Iif-- clinical program, which is an extension of the regional conference
          program, will consist of two or more coordinated educational activities
          conducted in a hospital on  a  given  day,  or,  on  occasion,  will  be  conducted
          on two successive days, with joint nurse and paramedical personnel
          participation.  The  procedures  to  be  used  will  be:  bedside  rounds,  seminar
          on  key  problems,  problem-solving  conference,  demonstrations  and   simulation.
          The clinical program will  be  under  the  direction  of  the  Associate  Dean  for
          Continuing Education of the  Medical  College  of  Ohio  at  Toledo,  who  is  also
          the Director of the Northwestern Ohio Institute for Continuing Medical
          Education.  Edited  videotapes  of  selected  regional  conferences  and   clinical
          programs will be made available for use by doctors and other health care
          personnel.  Single-topic videotapes will be prepared to be used by health
          professionals throughout the Region.  Closed circuit television backed up bY
          conference telephone is in the developmental state in this Region.  When
          developed, this will serve to  link  the  hospitals  in  Toledo  with  the  Medical
          College of Ohio  in  Toledo.  Approximately  $39,500  of  the  first  year's  total
          request of $63,609, is for personnel.
          Second Year:  $61,028                Third Year:  $63,609






              NOPI'IIWFSTERN Oti[O Regional Medical Program       - 3 -       RM  00063  7/70.1

                                                                                       Requested
                                                                                     First Year
              Project #17 - "Patient Problem Oriented" Education Program              $111,146
                             for Professional Nurses and Allied Health Personnel
              in Northwestern Ohio (Medical College of Ohio in Toledo).  This
              project was originally reviewed during the November/December 1969
              review cycle and was not approved, with the recommendation that
              the project be revised.  The initial objectives proposed for the
              series of oiie-day programs appeared to be over-ambitious and the
              entire proposal  would  not  contribute  positively  to  the  regionalization
              Process. Questions were  also  raised  regarding  the  lack  of  specific
              objectives in terms of behavioral changes, and the evaluation seemed
              co be little more than  pretesting  and  post-testing  with  no  followup
              lo determine whether the  acquired  information  was  translated  into  the
              individual hospital  situation.  Although  the  program  was  to  involve
              allied health personnel, there seemed to be  a  total.  lack  of  input  from
              this group in the planning of the program.
              According to the applicant, the revised proposal is designed to provide
              continuing education for nursing and allied health personnel in
              Northwestern Ohio.  The principal objective is to help bring about a
              regional distribution of appropriate knowledge to all nonphysician
              health personnel regarding current  trends  and  changes  in  the  concepts
              of care of patients with  heart  disease,  cancer,  stroke  or  related  diseases.
              Four subregional areas  (representing  21  counties)  have  been  geographica  ly
              identified.  Each subregion has a planning committee, composed of representa-
              tives of all health  personnel.  The  primary  faculty  at  the  Medical  College
              will consist of a full-time Health Education Coordinator, a Health Education
              Evaluator and an Audiovi.sual Technologist  who  will  be  responsible  for
              !Implementing and evaluating  the  program.  They  will  plan  cooperatively  with
              the subregional committees.  The  presentations  will  be  scheduled  on  a
              monthly basis throughout the year.  The location of the educational. programs
              will rotate within the four subregions.  Each presentation will include
              group discussions of predetermined patient problem situations, demonstrations
              and return demonstrations,  and  panel  discussions  of  actual  case  histories.
              [7ach session will be made  available  by  audiovisual  recordings  to  those
              individuals unable to attend the regularly scheduled program.  To provide
              for continuation of this activity beyond the three-year request for RMP
              support, each participant  will  be  charged  a  registration  fee.  In  addition,
              financial support of local units of the A.CS and the Heart Association are
              possible avenues of  continuing  support  after  termination  of  RMP  funds.
              A questionnaire will be given to each registrant and a followup questionnaire
              will be sent to each registrant, in an attempt to evaluate the program -
              indicating how this program has helped them increase the applicability of
              their own nursing skillsi understanding and attitude of patients.
              Approximately $45,000 of the  first  year's  total  request  of  $111,146  is
              for personnel.
              Second Year:  $iOO,803                     Third Year:  $104,180





          NORTHWESTERN OHIO Regional Medical Program       - 4 -         RM 00063 7/70.1

                                      HISTORY SUPPLEMENT

          LISTING OF CURRENT STATUS OF CORE AND OPERATIONAL PROJECTS IN NORTHWESTERN
          OHIO REGIONAL MEDICAL PROGRAM
          Project                                                    Amount Recommended
          Number      Title                                               First Year

          00          Core                                                $335,200*

            1         Stroke Education Program                              96,847

            2         Uterine Cancer Detection                              97,286

            4         Coronary Cdre Training                                88,176
            5         Improvement of Respiratory Care                       130,566
            6         Action on Smoking and Health                          33,392

            7         Dial Access Tape Library                              44,235



                                                          TOTAL            $825,702

          *Core is partially supported ($135,000) under the final year of the     planning
          grant.  Also, the Region was approved for a direct cost Cote level of
          $400,400 but elected to distribute $65,200 to newly approved projects.
          Thus Core is presently supported at $335,200.




















                                                                                  DRMP
                                                                                  5/19/70







             NORTIII,,TESTE,P,N'OIIIO REGIU@ql@L MEDICA,L PROC-;I@M RM 00063 7/70.1

                                       STAFF OBSERVATIOLN

             Project l@16 - A Prolcram in Con in@Lli2B M@dical Education for
                            in Northwestern Ohio.  This proposal was reviewed by the
             site visit team during the visit to the Region on May 21-22, 1970.

             Because of its similarity to Proposal #14 - A Program of Cont'  '-n
             Education for Physicians (which had been reviewed during the February/
             March 1970 cycle and was recommended for deferral pending a site visit),
             the site visitors reviewed both proposals simultaneously.  The team
             recommended that Proposal #14 be funded for one year as a feasibility
             study, in an amount not to exceed $75,000, and that the programmatic
             elements of Proposal #16 be merged with #14.

             Therefore, if this recommendation is approved, Project #14 and the
             programmatic elements of Proposal #16 will be merged and considered as
             a single study.

































                                                                             6/4/70




                                                                  A Privileged Communication

                              S Uli!@, T,, @Ly Of HELD CO CLUSIO'l-i OF
                                   JUINIE 1970


                          NOIITI-II,TESTERIQ OFflO REGIONZIL I,:,!@DICAL IIROCRAM
                                        RM 00063  7/70.1

                        FOR CO',,@'SIDEI.ZATION BY JULY 1970 ADVISORY COUNCIL


              Ceneral:  The Com.@aitte@ recommended that this supplemental operational
                         application 7/70.1, which requests $510,591 (d.c.o.) for a three-
              year program period, be partially funded at $10OV000, $50,000 per year for
              each of tiqo years, to support project #17 as a feasibility study, not to
              be included as a part of core.  Committee further recommended that the
              prograi,@iTnatic aspects of Project #16 be.-rq,--rged with Project #14 (see 7/70.2
              which is recowttiiended for fu-i.-tditif4,,,in in amount not to e3,-ceed $75,000 as a
              feasibfqltty stady for one year),'.
              Project #16 - A Pir-@riiii in r, L@i t             Education for LI-Lyr;
                          The Review Corri@ttittee, as did the site-vicitors, belic-,.vc@d this
                          proposal. to be so,3ii@ilar in  goals and objectives to Project ;r'14
                         of Coritill ,p  jLllcatil-,Il fo)-illiy,,j'   (see critique of'Projtct
              #14 in 7/70.2) that them two pre-,)cs@ls were reviewed simultaneously.
              Project @tl4 was recommended for approval for @Y75,000 as a one year feasi-
              bility study not to be included as a part of core.

                      flat      That the progranip@iatic aspects of this proposal bo i
                                with Project #14 described in 7/70.2.  l@otli thi@@,,e
              were the subject  of a site visit on May 21--22, 1970.

              Project ili@17 "Patient: Prol)leri              ti(,z Pro.@uarii for Prof,@,,@,,Bional
                             l.qLi.rses  and Al..i.ied    Pc,,rsc@n,,ir;@l

                         Thio project %,;as originally rovi,ei,@d during the Novetnl)er/Dc@cembei-
                         1969 R(,@,vici,7 Cycle with the recommendation -ttint it be returned
              for revis@.o:,-t.  The Review Co@nLiittee heard the report of the site visit
              team             The Coii-,@iiiittec also considered the review of the proposal'
              by the Continuing Education Training Pinel who recoii@.itionded it was feasible
              under e-J.@ E.,-Peci.fic con.@ditiortr@.  The Revi.e@,@@tre@       with the
              amount of pro--progracti plennlng efforts wh@@cli had         been
              on this propor)61.  It is supported by large plcziniii" coiis@.-iittees coml)os(@cl
              of representatives of all health perr@c)rinel in the region.  Although the
              proposal is strongly oi-.f.erteci to nurtj(,,,4z, the     need for the project
              was i-iell-f-,tatc-d             i@iitii the  @)@-ception of the distribution of
              allied        personnel.  l,"CliitbL-rs of the                  learned that
              this 13rof@os@-I has evol@.,,@d basically under ttie I.cacier,-lhip of the txL7,,) nurses
              oil    core staff.  IN'itti this ir,. mind, nid             the lack of lez,@det@.
              ship available in the Pegion (see. core 7/70.2), Letters of the Co@,@i,,i-tl.ttec,,







                   Northwestern Ohio PI,,Ill                           -   2                                      RM 00063   7/70.1


                   acting    on    the    recoviimendatic)ii    of    the    site    visit     team,     believed     that     the
                   program has  sortie merit and should be encouraged.   Although Comniittee  yes
                   convinced that  the pro,,ram should receive sou-!c-% support because of the
                   progress and momentum i,,I-tich has already been ,icliic@ved,  it was believed that
                   the budget requested was unrealistic.   This program might develop into the
                   Regiori's    first    example     of     a     truly     regionalized     program     -through     its     sub-
                   regional committee and interprofessional aspects.   The Co@mmittee concurred
                   with the recommendation of the site visitors and recommended approval as
                   a feasibility study, not as a part of core,  in an atriount not to excee
                   $50,000  (d.c.) per year for each of two years,

                   Rec6mtreiidation:   Approval as a feasibility study, not as a part of core,
                                              in   an    amount    not    to    exceed    @50,000    (d.c.)    per'    year    for
                   each of two years4








                   Nun-ibe r                      Title                 lst Year                  2nd Year              3rd

                      #16
                                              7 [Gain Coi:iti..I@ iLn      To be merged with Project #Ili.
                                                          ,_.   __L   _g
                                  Mer',.,ical Edticatirin For              (described in 7/70.2)
                                  Lhy ,@i        3

                      #17         it Patient Problem                       $50@000                $ 5 0, 0  0
                                  E d u ci ,-. i 0 FRI I          f   cx         (a@ a  feti@,;ibil.itV study
                                  Professional. liurs,-.s a,-id                   not to be included as
                                  Allied                 P(@rcoiiiiel              a part of core)

                                                             TOTAL         $50,000                @50,000


                   Ye r                                  TORT.A@L DIRECI' COL')I'@')'

                       01)                                        $50,000
                       02)                                      50,000
                       03)
                                     T(Yrt@L                     $100,000











                                                                                                                              -j I 0  7



                                                                                                                                                  m















            0                                                              0                                                              0








                                    DIVISION O@, REGIONAL MEDICAL PRO"RI@MS
                                                                            u
                         SUMMARY   OF   AN   OPERATIONAL    SUPPLEMENTAL    GRANT    APPLICATION
                                             (A Privileged Communication)

             N,)RTHWESTERN OHIO Regional Medical Program                  RM 00063 7/70.2 (formerly 3/70.1)
             2313 Madison Avenue                                          February 1970 Review Committee
             Toledo, Ohio  43624                                          March   1970   Council
                                                                          June 1970 Review Committee
             PROGPI,.,@'@  COORDINATOR:  C.  Robert  Tittle,  Jr.  ,   M.D.


             L_tatlt@,@L fLd
                       L:               Ist Year          2nd   Year       3rd     Year     TOTAL
             I)irect Costs:            $1,386,294      $     980,144      $1,009,523       $31375,961
             Indirect Costs:              267,276          275,902              286,215        829,393

             TOTAL                    $1,653,570          $1,256,046      $i,295,738       $4,26@@354

             History:  An initial planning grant was awarded              to this Region    be--
                         ginning January 1, 1.968 in the amount           of $274,450 (d.c.o.).
             A secor@d-year planning award of $271.,137 was supplemented and extended
             L@irough Junc 30, 1970.  The annualized level for core support during
             title first year of operational support is $335,200 (d.c.o.).  The prior-
             ities established during the planning period include.' 1) continuing
             medical education, 2) improved rehabilitative care, and 3) better and
             more prompt diagnostic methods.  The pr-Lrriary thrust will 'be to meet
             the   continuing   education   needs   of-   the   practicing   physician,   nurse,
             and allied health personnel.. The Region was approved for operational.
             status, effective July 1, 196ri including stippleine-(,.Lal support for core
             staff and six operational projects.  The award for the first year of
             operation of $825,702 (d.c.o.) is described belo@kT.

             Core                                                           $'@35,200@-

             llroject  #1   -   Stroke   Education   Program                     96,847
             Project   #2   -   Uterine   Cancer   Detection                     97,286
             Project #4 - Coronary Care Training                                88,1.76
             Project  4@'5  -  Improvement  of  Respiratorv   Ca@,@e            13C,566
             Project #6      Action on Srnokiig a-cicl Health                    33,392

                             Di.al Ac(-ess  Tape  lit)-L-ary                    144,235

                                                                               $825,702

               Partial support of core., ($135,()('@"') is from an administrative
                                                       "j
               continuation of funds from a -planning supple@.iierit.




                                                2 -                                              I
                                                                   RM 00063  3/70.1
            NORTHWESTERN' OFIO Regional Medical Program
            Alt@.ough the Region has submitted  several  additional  projects,  the
            Region has none in the approved but unfunded category.
            Present    lication:  This  application  requests  renewal  of  core
                                   support for  a  three-year  period  and  support
            for than new operational projects. One  of  the  projects  -  #15  -
            Council for Continuing Education -  Ottawa  Valley,  has  been  jointly
            requested by Northwestern Ohio RMP  and  the  Ohio  State  RMP.  The
            requested direct cost support is to be shared equally.
            Also, during the February/March Review  Cycle,  a  fourth  proposal  to
            support a Council on E     enc  Medical Care To DeveloD and Coordinate
                                            es  was  considered.  The  February  Review
                                   non-approval of the project  request  on  the  basis
            that it was inappropriate for  RMP  funding.  The  March  1970  Council
            concurred in this recommendation.  Direct Costs only are noted in the
            following project description.
                                                                                  Requ@s@ei  st
                                                                                  Year Renewal
            Core: The Region is  requesting  renewed  and  expanded  support  of   $452,114
                 . core staff in  the  amount  of  $452,114  (d.c.o.).  Although
            the region was approved for $400,400 (d.c.o.) for core staff
            during this period, it  elected  to  distribute  $65,200  (d.c.o.)
            among the newly approved operational projects.  As a result, Lhe
            present support for core staff is $335,200 (d.c.o.).
            The personnel category budget  request  reflects  an  increase  of
            $39,690 over the  currently  supported  six  full-time  professional
                                                        1 personnel  and  five
            personnel, five one-half time professions
            full-time secretaries.   This increase is   re-uested  to  support
            three full-time administrative assistants and one secretary.       One
            of the administrative assistants will be    responsible  for  budget
            preparation and review and the other two will 74or'@  as  liaison  per-
            sonnel between the various reference panels.     -Ehe  Region  accepted
            the advice of the preoperational  site  visit  team  of  April  7-8,
            1969 by increasing the staff to include an epidemiologist supported
            by both the Me@ical College of Ohio at  Toledo  and  ',,Northwestern
            Ohio RMP. They have  also  employed  an  individual  for  program  planning
            and evaluation, as  suggested.  The  other  budget  categories  request
            substantial increases over the current budget.     In the  category  of
            Consultant Services, increases in the public relatio-,is/photographic
            and system  consultants  are  noted.  Additional  equipment,  including
            office furniture, addressograph  and  other  mailing  equipment,  auto-
            matic typewriters (,\TrST), and electronic  data  processing  equipment
            is requested.
            The supplies, travel  and  publications  budgets  remain  unchanged.
            The request for '?6,,,310 in the Other category (a  $35,620  increase.)
            includes lease and operating costs  of  an  automobile,  insurance  for
            both liability and equipment, increases  in  record  fees,  rental  and
            utilities.
            Descriptions of the progress of- the  core  staff  in  developing  pro-
            jects, providing  consultation,  administration  of  funds  and  generating
            information are included in the narrative.     Changes in the organiza-
            tional structure of committees and the Board of Directors are discussed.
            01 Year:   t465.571                             car:  $479,700




         Northwestern Ohio RMP                              -3-                                   RM 00063

                                                                                                Requested Fir!-@t
          ore Renewal.                                                                          Year
         Cri@ue:  The Committee noted that the,             Region was last site visited in
                       April 1969.   At that time, the team expressed concern over the
         Region's extremely small Core Staff.   This was especially true regarding
         professional manpower.   The team recommended additional. staff, particularly
         in the area of planning and epidemiology, and suggested that the Region
         might wish to revise its entire staffing pattern in order to meet mole
         specialized program r@eeds.   The Committee noted that the Region had partially
         heeded ,-.he advice of the site vi.sit team by employing an epidemiologist
         and a director of program planning and evaluation.   Included in thi-s request
         are three fu'Ll-time administrative assistants, one of whom will assist the
         Regi,Dn in budget preparation, while the other two assistants will be liaison
         personnel, working with the various reference panels.
         Recommendation:   Approval at the c,,irrerit level of support ($335,200) and
                               deferral on the requested increase pending a site visit.

         Direct Costs Only:   lst Yr.                     2nd Yr.            3rd    Yr.
                                   $335,200               Deferred.             Deferred

                                   $116,914   defered)
      Project #13 - ComorehensiVe Stroke Proqram for the Northdesterii                      $802,42z'4.
                         2bio  R  ion.  'i"rii@j  proposal.   was   developed   by   the
    Oe,,?artments of Neurology and Neurological. Surgery at the @L4edical
         College  of  Ohio  at   Toledo.   @he   proposal   is   to   demonstrate   the   ways
         in  which  the  Medical  College  and  the  commu-c,,,-  -y   physician   can   interact
         to 'benefit ,;trol,;,e patients.
         'The objectives of the program are: 1) To detect the stroke@-
         pi-one   individual   and   institute   preventive   measures   2)   To    pro-
         vide  expert  treatment  for  the  acute  stroke   pat!-e-,it;   3)   To   pro-
         vide  rehabilitation  and   long-term   iyianafcineiit   of   the   pat@ientS'
         neurological   defic4@t;   and   4)   To   provide   the   necessary   services
         to allow the strong patient to function at               home rather ,-,hafi in an
         institution.
         in order to provide for the orderly accomplishment of tl-ese (3bjectl.ve-,,
         three  phrases  are  proposed  which   include:   1)   Setti.ng   up   a   4-bed   acute
         ,stroke unit at Maunic@e Val-ley hospital.,        a   county   hospital   to   which
         a 'riigl) perce@-)@-age of im7(--r cco@iciinic patients are referrf-,c.',.   -in addition,
         i-t is f)l.aiined to have the                 cqre unit become a iiioieL for
                                         f                                                  qp
         tiorsi-n)y care and a focal             for tl,ie  specialty  trai@-ilrig  of  nur,  -s;
         7@) A           care unit is to be established at thr- 560-I)ed LLIcas

               ti@ie  danger  of  acute  episode  has  gassed   and   the   patient",@   coil-
         Once
         ri,!,ti,or@ is stabilized, @e @7ill be transferred to this unit.             Tr@e.  unit
           tjlJ offer patient                    as   well.   as   rehabilitative    services.
            El unit is to be  staffed  '@)y  a  professional.  team  cc)ml.),.-.),ei  of  neurol-
            i, @q t -e i i r c,, s i i r 9 e G,,,t    ps,)cll@c,,Iogist, Speech pathological
         and an aiAdiologist.Plans are tO             lize an Il@.-,,.@ady established corylillu-
         nity referral. center ir                                  test- to this agency by
                                                                              of .-,everal type,,,





                                                                           RM 00063
        Northwestern Ohl-o RNP                -4-
                                                                                    Requested
                                                                                    First Yeer
        Subjective as well as objective evaluation plans are set forth.  The
        major portion of the funds requested are to provide staff ($2974344),
        equipment ($238,000), and renovate space ($223,400), for the two
        units to be established.
        Second Year:  $381,892                 Third Year:   $392,503

        Cri@ue:  February 1970 Review Committee.
        Project #13               ve Stroke  I            the Northwestern
        Crit@ue:  The  Review  Committee   was ambivalent about this project.  On one
                   hand$ it was  felt  that  acomprehensive stroke program would provide
        a valuable service in the Region, while on the other hand, it was concluded
        that the program (as described) did not adequately assess the reasonableness
        of establishing a classic, acute intensive care unit, a nodest extended-
        care program, and a community referral center unit.  The Committee felt
        that the proposed program was incompletely defined and inadequately planned.
        The problems associated with stroke are well presented but the methodology
        or "know-how" to approach the solution of such problems Is lacking.  Then too,
        it was apparent that a minimum of planned correlation had occurred between
        the activities of the proposed group of facilities.  Serious consideration
        was given to a recommendation of nonapproval as suggested by both Staff
        and outside expert reviewers.  However, since other components of the
        application were deferred for a site visit, the Committee believed that
        this project should also be included in the site visit.
        Recommendation:  Deferral for a site visit.
        Project #14 - A Pr         f Continuing Educatio             cians    $110,926
                      'in Northw             .  This proposal was  eveloped
        by the Northwestern Ohio Institute for Continuing Medical- Education
        (N.W.O.I.C.1l.E.), Medical College of Ohio at Toledo.  The N.W.O.I.C.M.E.
        was organized in 1966 and currently has'the cooperation of physicians
        in nineteen of the twenty counties in the Region.  Each county,
        through its medical  society,  has  appointed  a  representative  to  the
        institute  who  is  designated  as  "county  continuing  education  coor-
        dliiator" and functions in both  planning  and  implementation  in  his
        area.   In addition,  the  identification  of  hospitals  in  the  Region
        as "learning centers" for continuing education, with partici-
        Pat:ion by hospital staffs has been accomplished through a pro-
        gram of regional conferences initiated as a pilot study in
        September 1969.

               4
        The tr.ple objectives of the proposal are: 1) To plan, develop
        and implement  programs  of  continuing  education  for  physicians  in
        1-he nin:ateen county areas which are to be based on the needs
        ",deiiti ied by thhe )li 1-i-cians.  The basis for this objective is
        a  "Physician  Continuing  Education  Profile"  which  has  already  been
        compiled for these doctors;  2) To evaluate these programs; 3)
        Through liaison membership of the N.@NI.O.l.C.M.E. , to maintain
        effective  communication  and  optimum  coordination  with   continuing
        education planning and implementation of other health professional



         Northwestern        RMI-'                                         RM    00063 Requested
    46                                                                                 First Year
         Detailed planning  at  the  county,  slib-regiorial  (st-veral  counties)  and
         Regional  levels  will  provide  the  types  of  'Learning  experiences  needed
         to  achieve  defined  objectives  within  a  particular  area.   This   action
         phase of the proposal will be based at the "learning center" hospitals.
         'rhis is a companion  proposal  to  project  #9  -  A  Program  in  Continuing
         Medical  Education  for  Physicians  in  Northwestern  Ohio  which  was   re-
         turned for revision in the December 1969 Review Cycle.
         'i@-urtiier implementation of programs will derive from a planned comn@-ini-
         cation  and  coordination  process  which  may  include  such  methods   and
         tools as use (,,f television, tape recordings, visiting experts and cir-
         cuit rider sessions.
         Also, based on  the  results  of  the  physician  sL.Irvey,  counseling  ses-
         sions may  be  conducted  with  individual.  groups  of  physicians  in  indi-
         vidual counties.
         A "continuing education calendar of events"  wi..ll@  be-  I?ubl.ished  three
         times each year which is Lo pro@-ide  infor-i,,ia@ion  about  program  a.ctiv-
         ity within the Region.
         This applicant  proposes  to  divide  the  nineteen  Da,r@,ici.pating  counties
         into Five sub-regions.     BI.-y'--arly workskic)-) sessions in each of  these
         geographic areas are planned.
   .Second Year:  $112,156                         I"hird Year: $116,070

         Critique:  February 1970 Review Comittee.
         Project #14 - A Program for  Continuing  Education  for  Pliv-@.i-cians  irk
                        Northwestern Ohio.
         Critique-.  The Committee agreed with the Continuing Education and Training
                     Panel that this project's 7,7hole concept was premature since the
         continuing education  needs  of  local  physicians  are  to  be  based  on  a
         questionnaire  -  the  results  of  which  are  incomplete.   The   proposed
         methodologies were considered weak and vaguely described.  Committee bel.ieved
         that  ,,!his  project  presented  a  preliminary  planning  methodology  for
         determination of program content rather than an operational program in
         continuing education.  Based on the abo-ve, it was impossible for the re-
         viewers to assess the rea',.. objectives or feasibility of the project.  The
         Committee, in line with                      the              Educ,atior,. and
         training Panel, seriously considered recommending that this apl-,I.ication not
         be approved.  In view of the site -v4.,3it recommended for other co,@q-,L,@onents,
         it seemed appropriate to include t@iis project.

         Recommendation. @, Deferral         si,t-.e visit.
         0




    Northwestern Ohio RNP             -6-                             RM 00063

                                                                           Recuested First Yea-
                                                                           $20,830 (NWORNP
    Iroject #15 - Council for Continuing Education:      o ect                        1 6 0
                 to Develop Organized Educational Programs for             Total of $4 1 6
                                                                           be awared equaii@
    lealth Professionals of the Ottawa Valley Area.  This project          between NWO and
    s sponsored jointly with the Ohio State  Regional  Medical  Program
                                                                           Ohio State FYN-
    which has submitted for this review cycle, an  identical  project  (#22)
    Responsibilities and objectives will be shared by both Regions.
    Therefore, it is requested that each Region should  be  awarded  exactly
    one-half of the direct costs for each project year.

    Projects similar to the activities proposed in  this  program  have
    been approved for the Springfield and Portsmouth areas, but a third
    proposal for the greater Mansfield area was  recommended  for  dis-
    approval during the December 1969 review cycle.
    The project proposes to develop a Council for Continuing Education
    composed of the leadership from all health professions in  the  Ottawa
    valley area.  The proposal is presented in three phases.  The
    first phase will involve basic organization and the hiring  of  a  full-
    time director. Cooperative arrangements are to  be  established,  med-
    ical education programs conducted, and  record-and  information  systems
    developed.  In Phase II, a two-year schedule of educational activities
    is to be developed to allow health professionals to plan  their  long-
    term involvement in educational activities.  A bibliography of
    available educational materials is to be compiled and distributed.
    Phase III is to involve a basic process evaluation of the first and
    second years of the project with additional  coordination  and  develop-
    ment of the program.
    The project generally intends to coordinate existing continuing
    education opportunities, to create new programs to meet documented
    needs, to act as a clearinghouse for information, and to evaluate
    the total program.
    Second Year:  $20,525             Third Year:  $21,250

    Critique:  February 1970 Review Committee.
    roject #15 - Council for Continuing Education    A Proiect to  Develop
                organized Educational Programs for] ealth Professionals of
    he Ottawa Valley Area.
    @ritique:  The Committee noted that this project was cosponsored by the
             Ohio State RMP and Northwestern Ohio RMP.  Further, it was noted
    @hat the Ohio State RMP had previously submitted three identical proposals.
    'he first,for a project in Springfield, was approved and funded for one year
    fith RMP carryover funds.  The Ohio State RMP hopes that the experience
    )f the Springfield project will assist in designing an approach to improve
    -he delivery of health services in a community away from a medical center.
    @ second project in Portsmouth was recommended for approval but has not yet
    )een funded.  The third proposal for a project in Mansfield was not recommend-
    id for approval; the Advisory Council felt that the Region should present
    evidence of progress for the first two projects before additional programs
    ire approved.
    .'ommittee noted the similarity between this application and those previously
    3ubmitted by Ohio State       All of the proposals have been general and
                                                  @,,ncfinn Aq to what could be








                                                                       RM 00063
         Northwestern Ohio 'FII)P                                       Requested
                                                                        First Year

         Serious consideration was given to recommended that this project not be
         approved since the Ohio program has not been operating long enough to
         provide any concrete results.  However, since a site visit had been
         recommended for other components of the application (and the Northwestern
         Ohio RM@l is venturing into this area), Committee believed this project
         should be included in the site visit in order to determine the importance
         of this and similar projects to the overall plan of the Region.

         Recormiendation.-  Deferral for a site visit.



         March 1970 Council Action
         Northwest Ohio Regional Medical     ram
         Approval with specific conditions recommended by the Review Committee.
         (This includes a site visit for projects #13, #14, and #15 and this
         increases for core)
             01 - @335,200          02 - $0          03 - $0
                   Core
         Site Visit - May 21-22, 1970.  A report will be available during the
         June 1970 Review Committee Meeting.



















                                                                       DRMP
                                                                       6/l/70





                                                            (A  Privileged   Communication)

                            SU @ RY OF REVIEW AND CONCLUSION OF
                            JUNE 1970 REVIEW COMKITTEE

                            NORTHWESTERN OHIO REGIONAL MEDICAL PROGRAM
                                        RM 00063 7/70.2

                        FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL

          General:  The Committee recommended that this supplemental operational
                    application which requests  $2,095,490  (d.c.o.)  for  a  three-year
          program period, be partially funded for $75,000 to support Project #14 for
          one year only as a feasibility study and  that  the  programmatic  aspects  o
          Project #16 (see 7/70.1) be merged with Project #14.  Committee further
          recommended that the $116,914 requested for the Core increase not be approved
          and that no funds be committed for Core for the third and fourth year renewal.
          The reviewers further recommended that Project  #13  not  be  approved  (revision
          required) and that Project #15 be  deferred  pending  Council's  decision  on
          this type of program.
          This entire application was reviewed during the February/March 1970 review
          cycle.  The original application requested $452,114 for first-y6ar Core
          renewal, plus $465,571, and $479,700 (d.c.o.) for  the  third  and  fourth  vears
          respectively.   However, March 1970 Council recommended approval of Core at the
          current  amount allocated ($335,700) and deferral  on  the  $116,914  increase
          pending a  site visit. The site visitors were  also  asked  to  recommend  the
          amount of  Core support for future years.
          In addition  to reviewing the Core component,  Council  recommended  that  the
          site .visitors review Project #13 (Stroke) and  Projects  #14  and  #15  (both
          proposals for continuing  education).  Also,  the  reviewers  believed  that  the
          site visit team should study the entire  operational  structure  of  the  Region,
          including the total regional plan,  identification  of  needs,  assessment  of
          objectives and priorities. The site visit  was  conducted  on  May  ?1-22,  1970.
          The chairman of the site visit team presented  the  team's  findings  to  the
          Review   Committee.

          Project #00 - core.
          Critique: The reviewers were advised by the  chairman  of  the  site  visit  team
                      that particular attention was given to the  Core  Staff  and  its
          functions because of the critical comments made  by  both  the  Review  Committee
          and the Advisory Council regarding  past  applications  from  this  Region  (with
          resulting deferral or nonapproval of all projects during the last two
          review cycles.  It was found unsatisfactory in the following respects:
            1) Although the Region appears to have  responded  to  the  suggestion  of  the
               April 19, 1969 site visitors -  that  a  program  planner-evaluator  and
          epidemiologist be added to Core staff - it became obvious early in the
          May 1070 site visit that neither of the  individuals  appointed  to  these  posts
          had sufficient past experience or background  to  perform  the  required  duties.





            NORTHWTSTERN OHIO Regional 14edical Program        - 2 -       RM  00063  7/70.7

            The epidemiologist even appeared to be unfamiliar with the goals and
            objectives of RMP, and @he team gained  an  impression  that  he  was  more
            interested in how the RMP could  serve  his  medical  school  program  than  in
            how he could serve the purposes of RMP.

              2) It was clearly evident that the  physicians  who  serve  as  chairmen  of
                 the three reference panels (heart,  cancer,  and  stroke)  and  who  are
            supported 50'/. of time from Core budget, were devoting  far  less  than  50%
            of their time to the function of  planning  and  project  development  in  their
            categorical areas.
              3) While one of the major objectives of this Region is continuing medical
                 education, there is no full-time  Core  staff  member  who  is  responsible
            for the coordination of this effort.

              4) The site visitors were provided  with  an  organizational  chart  but  it
                 became clear that the listed functions are not well-defined and bear
            little relation to position titles.  In  fact,  the  impression  was  that  "all
            people do all things."
              5) The Region has requested support for three new administrative assistants
               . as a part of Core renewal but,  in  fact,  their  functions  were  not
            yet, defined. ,
              6) The preparation of budgets is haphazard and seemingly the budgets have
                 been carelessly reviewed since the same item may appear in two places,
            but for different amounts.

            The-team was unanimous in its belief that the Program Coordinator is a
            sincere, devoted, dedicated physician who  has  won  the  admiration  of  his
            staff and his peers.  He has tried to provide the leadership that is
            required but has not yet been fully successful in doing so.

            It is evident that Core staff functions and responsibilities must be more
            precisely defined and lines of authority and responsibility must be
            delineated more  clearly.  The  present  arrangement  of  part-time  personnel
            in key administrative posts is clearly unsatisfactory.
            In view of this dismal report, the Review Committee concurred with the
            site visit team's recommendation  that  the  $116,914  requested  for  Core
            increase not be approved, that no  RMPS  funds  be  recommended,  and  that
            the amounts requested for future support be denied at this time.

            Recommendation:  Nonapproval for $116,914 above the current amount
                              allocated to Core support  ($335,200)  -  no  RMPS  funding
            recommended - and that the amounts  requested  for  future  years  of  support
            not be approved at this time.





           NORTHWESTERN OHIO Regional Medical Program     - 3 -       RM 00063 7/70.2

           Project #13 - Comprehensive Stroke Program.

           Critique:  The;reviewers heard the report of this proposal by the chairman
                      of the site visit team.  The Committee observed that the proposed
           Project Director is presently supported for 50'/. of his time or effort As
           Chairman of the Stroke Reference Panel.  After reviewing the program, the
           Committee concurred with both the expert outside reviewers and Staff's  review
           of the proposal,and agreed with the site visitors that this program is
           premature.  For example, the Maumee Valley Hospital (Medical School Teaching
           Hospital) is not presently prepared to carry out this type of comprehensive
           program - even if the requested equipment should be provided. It  was  thought
           that the existing stroke personnel and facilities in the Region are not  being
           fully utilized at the present time.

           in recommending nonapproval, the Committee believed that the Region should
           conduct more detailed planning.  The Review Committee, in line with the
           site visitors'  suggestions, felt that the revised application could be
           strengthened by better justification and clarification relating to the
           following concerns

             1) Fetter identification of sources of patient material.

             2) Identification of need for a comprehensive stroke program in the  Region.

             3) Relation of this new proposed facility to facilities already existing.

             4) An exploration of cost-sharing with other agencies.

             5) A commitment should be obtained from the Medical School, stating how
                much of an anticipated $3,000,000 (to bring the hospital up to  community
           hospital standards) would be apportioned to the proposed stroke unit.

             6) Better delineation of Project Diredtor's time with regard to
                project, RMP, hospital, and teaching responsibilities.

             7) Detailed listing and justification of equipment.

             8) Concrete evidence of support from the medical community.

             9) Phase-out plans.

           Recommendation:  Nonapproval - revision required.




          NORTM4ESTERN OHIO Regional Medical Program         - 4 -       RM 00063 7/70.2
          Project #14 - A Program of Continuing Education for Physicians.
          Critique:  The Continuing Education and Training Panel recommended non-
                     approval of this proposal on  -technical grounds - because the
          proposal did not contain enough information to  make  a  judgment  concerning
          educational design and the methodologies were too vaguely described.
          However, the Review Committee was informed of the site visitors' belief
          that this proposal may act as a catalyst to bring  about  a  more  concerted
          continuing education program,to replace  the  present  scattered  continuing
          education endeavors now existing within the  Region.  The  team  was  advised
          that cooperative arrangements have already been made  for  the  program  via
          the Medical College, the County Medical  Societies,  Heart  Association,  the
          Cancer Society and others.
          Discussion of planning, implementation, and evaluation gave the site visitors
          some confidence that the proposal represented more  than  a  fond  hope.  The
          Committee acknowledged the commentary of  the  Continuing  Education  and
          Training Panel, but expressed an opinion (as did the  site  visit  team),  that
          this Region is beginning to make some sincere efforts in continuing education.
          In view of this decision, the reviewers believed  that  more  planning  time
          is needed to allow the Region to coordinate its continuing education efforts.
          Therefore, the Committee recommended that this program  be  funded  for  one
          year (instead of for the three years requested), in an  amount  not  to  exceed
          $75,000 (d.c.). The reviewers further recommended  that  the  funds  be  used
          to support a feasibility study and are not to be included as a part of Core.
          Because Project #16 - A Program in  Continuing  Medical  Education  for
          Physicians (see 7/70.1 RM 00063) is similar  in  goals  and  objectives to  this
          proposal, the two proposals were  reviewed  simultaneously.  It  was  amatter
          of some concern to the Committee and to the site  visitors,  that  these  over-
          lapping projects (requesting identical personnel and  giving  no  real  hint
          as to interrelationships with other  continuing  education  programs)  should
          appear in the same package. The  Committee  recommended  that  the  program-
          matic elements of Project #16 be merged with this proposal.
          Recommendation: Approval for one year as a  feasibility  study  (not  to  be
                           included as a part of Core), in an  amount  not  to  exceed
          $75,000 (d.c.) and, further, that the programmatic elements of Project #16
          be merged with this project.
          Project #15 - Council for Continuing Education -  A  Project  to  Develop
                        Organized Educational Programs  for  Health  Professionals  of
                        the Ottawa Valley Area.
          Criticue: This is an attempt (in conjunction  with  Ohio  State  RMP)  to
                     establish a Council for Continuing  Education  in  which  both
          Regions would equally share objectives and responsibilities.
          Again, the Review Committee heard the report  of  the  team's  findings
          pertaining to this proposal. The reviewers noted  that  the  program  had  been





         NORTHWESTERN OHIO Regional Medical Program       - 5 -       RM 00063 7/70.2

         reviewed unfavorably by staff of the Continuing Education and Training Section
         of RMPS.  It w,as further observed that here, once again, information gained
         during a technical visit was superior to the written word.  In fact, the
         site visit team was favorably impressed with the need, objectives, procedures,
         and evaluation of the program.

         Members of the Committee were advised that the program should serve the
         following purposes:  1) generate enthusiasm for a program to be sponsored
         locally; 2) involve'all health professionals in a planned educational program*,
         3) encourage subregionalization and utilization of what is already available
         in the Region; 4) serve as an aid in the recruitment and training of health
         personnel; and 5) coordinate with Comprehensive Health PI'Anning activities.

         The Review Committee, in spite of the favorable impressions gained by the
         site visitors, hesitated to recommend approval.  This was because of Couhcil's
         decision not to consider funding of additional programs until such time as
         evidence of satisfactory progress on similar ongoing projects has been
         presented.  (A similar project in Springfield, Ohio - OSRMP - has been funded,
         and a second project in the Portsmouth area - OSRMP - has been recommended
         for approval.)

         The Review Committee recommended deferral in view of Cotincil's decision.
         However, it was further recommended that the Region be encouraged to include
         some of the activities from this proposal in the Continuing Education
         Feasibility Study which was recommended for funding as Project #14 (described
         above).

         Recommendation:  Deferral pending Council decision.







                                                                               RM
           NORTHWESTERN OHIO R,'--gio-,ial Medical Program      - 6               00063 7/70.9

                                     SUMMARY OF RECOMMENDATIONS


           Project
           Number:  Title                               ls.t Year (R)       3rd Year     4th Year

           00         Core                              Nonapproval         None         None
                                                        of renewal
                                                        increase
                                                        ($116,914)  -
                                                        No RMPS funding

                                                        rec
                                                        Ist  Year           ?nd Year     3rd Year

           13         Comprehensive Stroke              Nonapproval
                      Program                           revision
                                                        required
           14         Program  for Continu@             $75,000             None         None
                      Education for Physicians          (as a feasibility
                                                         study -  not  to  be
                                                         included as a part
                                                         of   Core.)   Further,
                                                         that  the   programmatic
                                                         aspects of Project #16
                                                         be  merged  with  this
                                                         project.
           15         Council for Continuin&             Deferral  pending Council
                      Education - A Project to           decision
                      Develop Organized
                      Educational ProRrams for
                      Health Professi@nals of
                      the Ottawa Vallev Area


                              TOTALS                    $75,000             None         None


           Year                                                Total Direct Costs
           01                                                           $75,000
           02                                                            None
           03                                                           -None

                                                     TOTAL              $75,000






                                                                                        7/16/70








                                                        A PRIVILEGED COMMUNICATION
                                                        RM 00063



                                    SITE VISIT REPORT
                      NORTHWESTERN OHIO REGIONAL MEDICAL PROGRAM


                                   MAY 21-22, 1970


        SITE VISITORS

        George E. Miller, M.D. (Chairman), Member of RMPS Review Committee
          Director, Center for Educational Development
          University of Illinois College of Medicine
          Chicago, Illinois  60612
        Charles B. McCall, M.D.
          Program Coordinator, Texas Regional Medical Program
          The University of Texas System
          Main Building 101
          Austin, Texas  78712
        Lee A. Cliristoferson, M.D.
          The Neuropsychiatric Institute
          P.O. Box 32
          Fargo, North Dakota  58102

        STAFF, REGIONAL MEDICAL PROGRAMS,SERVICE

        Mr. Joseph T. Jewell, Public Health Advisor, Grants Review Branch
        Mrs. Jeanne L. Parks, Public Health Advisor, Grants Review Branch
        Mr. James Smith, Operations Officer, Programs Assistance Branch

        NORTIIWESTEP,IN OHIO REGIONAL MEDICAL PROGRA-14 STAFF


          Full-Time


            *C. Robert Tittle, Jr., M.D., Coordinator
             Donald A. Grubb, M.B.A., Associate Coordinator for Administration
            *,James A. Pullella, M.P.H. Public Health Specialist
            *I,oalouise Geiger, R.N., Nursing Research/Lecture Pssociate
             James B. Felkey, B.S., Systems Communications Specialist
             Cynthia Ann Haskell, R.N., Nurse Associate


          Half-T@Lme

            *Herman W. Reas, 14.D., Associate Coordinator for Program Planning
               and Evaluation
             Anders Otterland, M.E., Ph.D., Associate Coordinator for Epidemiology
            *Louis A. Black, M.D., Chairman, Heart Reference Panel
            *Anthony Iannone, M.D., Chairman, Stroke Reference Panel



        *Dual listing





       NORI@HWE@TERN OHIO RMP Site Visit          - 2 -                RM 00063

       EXECUTIVE BOARD AND REGIONAL ADVISORY GROUP

       William T. Collins, M.D., Chairman, RAG
         Department of Pathology, Lima Memorial Hospital
       Glidden L. Brooks, M.D., President, Medical College of Ohio at Toledo
       P-rian K. Bradford, M.D.
     *Howard S. Madigan, M.D., Director, Northwestern Ohio Institute for
         Continuing Medical Education
       Edwin R. Murbach, M.D.
          John E. Paplow, Executive Director, Lima Memorial Hospital
       John L. Zimmerman, M.D., Memorial Hospital of Sandusky County

       ,@.EFl-7RENCE PANELS

         Cancer - Miss Helen Dickman, R.N., representing Chairman Daniel J. Hanson, M.D.

         Lleart -*Louis A. Black, M.D., Chairman

         '@@rol@-e -*Anthony M. Iannone, M.D., Chairman

         Re.l@,led Diseases -*Ilerman W. Reas, M.D., Chairman

       Cl)'.@-,IITTEES


                    Medical Education -*Howard S. Madigan, M.D.

         ..n.forr.-.ation Systems - *Mr. John E. Paplow

       "'@@'@,%TIONAL PROJECTS

         .,tronarv Care Training for Nurses.- Miss L. Ferris, R.N., Project Director

                Cancer Detection - Mr. Thomas Boesel


             Access Tape Library -*C.R. Tittle, Jr., M.D.

               Rehabilitation for Registered Nurses and L.P.N.s

           1. Richard Baer, M.D. (Stroke Panel)
           2. I'heresa Sutterlin, R.N.
              Sister Gabrielle, Little Sisters of the Poor

         "-rthwestern Ohio Action on Smoking and Health    *Mr. James Pullella and
         @,-IT. J. Kenneth l,angdon

                  -it of R  -piratory Care in an Extended Care Facilit
                        -es
          i      O'Crady, M.D.


               I isti@-ig








          NORTHWESTERN OHIO RMP Site Visit          - 3 -                RM 00063


          OPERATIONAL PROPOSALS CURRENTLY UNDER REVIEW


            Comprehensive Stroke Program for the Northwestern Ohio Region -
              *Anthony M. lannone, M.D.

            A Program of Continuing Education for Physicians in Northwestern Ohio -
              *Howard S. Madigan, M.D.

            Council for Continuing Education for Health Professionals in Ottawa
              Valley Area (submitted jointly with the Ohio State RMP) -
                *I;illiam Collins, M.D. and Mr. Braxton Tewart (Ohio State RMP)

            Program in Continuing Medice.1 Education for Physicians in Northwestern
              Ohio (Regional Clinical-Co4!ferences) - *Howard S. Madigan, M.D.

            "Patient Problem Oriented" Educational Program for Professional Nurses
               and Allied Health Personnel in Northwestern Ohio -*Loalouise Geiger, R.N.


          COMPREHENSIVE HEALTH PIANNING


          Jeff Drake, Planning Associate
          Cordon C. Smith, Project Director, Comprehensive Health Planning Association
            for Creater Ottawa Valley
          *J. Xenneth Langdon, Wood County CHP


          HOSPITALS


          Mr. Charles Cliffe, Assistant Administrator, The Toledo Hospital
          Randolph P. Whitehead, M.D., Director of Medical Education, St. Vincent's
            Hospital and Medical Center


          SYSTEMS CO@TNICATIONS


          Thomas Browning


















          *Dtial listing






         NOETHWESTERN OHIO RMP Site Visi.t        - 4 -                RM 00063
         Bac    nd Of Northwestern Ohio RMP.   This Region comprises twenty counties

                                               with an area of  8,635  square  miles,
         and has a total population of approximately 1.4 million people.    It is  an
         industrial area, with 90'/. or more of the employed population engaged in
         nonagricultural occupations.  Approximately 73% of the Region's population
         is concentrated in urban areas.  92% of the population is white.
          There is a new medical school, the Medical College  of  Ohio,  located  in
         Toledo. There are approximately 1,300 M.D.s in addition to 120 D.O.s

         within the Region.
          The Northwestern Ohio R-MP is joined to the south by the Ohio  State  RMP,
         based in Columbus, Ohio, and to the east by the Northeastern Ohio RMP

              ir, based in Cleveland.
          The present Program Coordinator, C. Robert Tittle, Jr., M.D., was

         appointed in July 1967.
           @i@e 1,2st site visit to the Region was conducted during April 1969.   In
                  the critique of the Region by this group was:    The site visit team
             'L@e impression that the new medical school and the Regional Medical Program
           7@- -,-,,-rking somewhat independently of each other; that the Core staff was
         too administration oriented, needing stronger  professional  and  technical
         backup; and that data collection was not pertinent to program needs.     On
         the other hand, the team believed there was good interaction with other
         @,ealLli-related programs and that the key strength of the program was  the
         active n(ipport given it by the private medical sector.






         NORTHWESTERN OHIO RMP SITE VISIT          -5-               RYi 00063

           r o (-, of Site Visit. The site visit was conducted for two  purposes:

                                 First, to explore the present interrelationships

         of the Core staff with current operational projects as well as  the  degree

         of coordination of the Core staff with the Medical College of  Ohio,  at

         Toledo. The team was interested in evaluating progress  that  had  been

         made in developing a comprehensive regional plan - how needs  have  been

         (or are being) identified; resources assessed; objectives  defined;  and

         priorities set. The site visitors wanted to learn  what  interests  and

         groups had been involved in this total process; and how various

         interests and other programs fit into the Regional Advisory  Group  and

         other regional panels and committees.
           In addition, the team was interested in ascertaining the Region's

         concept of the role of the Core staff and more specifically, in the

         structure and activities of the present staff when considered  in  relation

         to the additional staff members requested.

           The March 1970 Advisory Council recommended that the Core  renewal  be

         approved at the Region's current level of support ($335,200) and  that  the
         Region's request for a Core increase of $116,914 be deferred  pending  this
         site visit.  A request that the site visitors recommend a Core level for

         the second and third years was included in Council's recommendation.

           Second, the site visit team was interested in reviewing with the applicant,

         three of the four individual proposals contained in the  November  1969

         supplemental application - Comprehensive Stroke      ram;
         Education Program for Physicians; and a                          uncil  for

         Continuing Education.  In addition, they were asked to review two





        NORT[iWl-'STERN OHIO RMP SITE VISIT     -6-                 @l, 00063
        additional proposals (both cLf which are revisions of proposals

                                                                               for
        previously submitted): 1)
                  ; and 2) "Patient Problem Oriented" Educational Propram for

        Professional Nurses and Allied Health Personnel.

        General Observations.
          1) The site visitors were impressed by the  number  of  interested  groups
             which had been mobilized to show their  support  for  the  Northwestern
             Ohio RMP.  These included professional organizations, voluntary health
             agencies, educational institutions and interested individuals.  However,
             no representatives from the Black community  were  present  during  the

             meeting.
          2) The team was shown strong evidence of apparently excellent cooperation
             a)-id open lines of communication between the RMP and the Comprehensive
             '@1.2a!tll Planning "B" agencies. The same statement may be applied  to
             the rapport established between the @ and the Hospital Association.
          3) The Medical College of Ohio at Toledo and the PIT were started at
             approximately the same tim@.  As a result, a relationship has been
             dc-,reloped between these two institutions ,7hich has facilitated the
             establishment of very  favorable  cooperative  arrangements.  The  site
             visitors left the meeting with the impression that the Medical School
             was not attempting to dominate the PW .    This can be said in spite of
             the fact that a majority of the members of the Core staff have Medical
             Sc!-t,,)o,l appointments.  Dr. Glidden L. Brooks, President of the @tedical
             College of Ohio at Toledo, testified that the RMP  was  viewed  as  the
             Colloge's arm into the community.  He also stated that they had
             ),,-!..@-nessed no problems between it town and gown." Dr. Brooks stated that








        NORTHWESTERN OHIO PM SITE VISIT        -7-              Pli 00063

             the Medical School did, in fact, have an indirect veto power over

             the activities of the RNP, although it was never exercised.  The

             Dean of the Medical School was not present during the site visit

             but the team was advised that he is kept informed of RMP  activities

             by the President. Dean Page s training is in cardiology and  he  is

             a consultant to the Heart Reference Panel.

          4) The site visitors were pleased to hear of this Region's good

             relationships with its neighboring Regions.

          5) The team was disappointed that the outreach of the program  appears

             to be concentrated in the Toledo area, with some involvement in  the

             Lima and Sandusky areas, while the remainder of the Region  appears

             to lie dormant.

        Regional Advisory Group. The team was interested in  the  presentation  made

                                  by the Chairman of the RAG, Dr.  William  Collins,

        who seemed committed to the RNP and was very knowledgeable of the  goals,

        priorities, and the national objectives.
          The Regional Advisory Group is composed of approximately 50 members, and,
        according to the Chairman, represents all "walks of life" and all  parts  of

        the Region. Like so many other Regions with a large RAG,  attendance  at
        quarterly meetings varies between poor and average. While all  five  sub-
        regions have representatives on the RAG, the site visitors were concerned

        over the imbalance of this group and particularly by the absence of

        representatives from the Allied Health Professions.  While two nurses

        currently are members of the RAG, the Chairman of the  Nominating  Committee






       NORTHWESTERN OHIO RMP SITE VISIT       -8-            RM  00063
       is preparing a slate which will include two additional nurses, a dentist
       a pharmacist, and a podiatrist. The Black community is  represented  by

       only two members.
         The site visitors were aware that the constitution and bylaws of  the

       NWO'RMP had recently been revised to read: "No individual who draws
       remuneration from the Regional Medical Program shall be eligible for
       membership on the Advisory Group."  But the current RAG listing continues
       to include Core staff members.  The team was advised that this would be
       corrected in the new RAG listing. The site visitors were  advised  that
       the overall function of the RAG was to implement programs to satisfy
       the medical needs of the Region as empowered under Public Law 89-239.
       To accomplish this, the group receives, reviews and acts on  individual
       proposals, and provides an appeal mechanism for proposals rejected by

       Core staff, reference panels and others.
         The Chairman of the RAG indicated that priorities are set by this group.
       He admitted that in the past this has been accomplished in a  haphazard
       fashion and was confined to priority ratings of individual projects.  It
       was also noted that very few projects are generated at the "grass roots"

       level.
       Executive Board. Recently the administration of the Region has been
                        reorganized and an Executive Board established to combine
       functions of the former Board of Directors and the Executive Committee.
       Its membership consists of the officers of the RAG, the immediate  past
       Chairman of the RAG, a member of the RAG who shall be a  representative
       of, and appointed by the grantee agency, and four members-at-large. The







         ,NORT[IWESTEILN OHIO @ SITE VISIT      -9-         PM 00063

         Executive Board functions as the executive arm of the RMP.  It arranges

         for a Grantee Agency and coordinates the activities of the Regional
         Medical Program with those of the Grantee Agency.  It also has direct
         aijthoriity over the Program Coordinator in directing the activities of
         the RW .  It appears at the moment to be far more involved in direct

         management decisions than is appropriate for a policy group.
         Core.  In view of the critical comments regarding past applications from
                this Region that have been made by both the Review Committee and
         the Advisory Council (with resulting deferral or nonapproval of all
         projects during the last two review cycles), the site visitors gave
         particular attention to the Core Staff and its functions.  it was found
         unsatisfactory in many ways. For example: 1) Although the  Region  appears
         to have responded to the suggestion of the April 19, 1969 site visitors  -
         that a program planner-evaluator and epidemiologist be added to Core
         staff - it became obvious early in the site visit that neither of the
         individuals appointed to these posts had sufficient Dast experience or
         background to perform these duties.  The epidemiologist even appeared to
         be unfamiliar with the goals and objectives of RNP, and the team gained
         an impression that lie was more interested in how the RMP could serve his
         medical school program than in how he could serve the purposes of RMP.
         2) It was clearly evident that the physicians who serve as chairman of
         the three reference panels (supported 50% of time from Core budget),  were
         devoting far less than 50% of their time to the function of planning
         and project development in their categorical areas. 3) While one of the
         major objectives of this Region is continuing medical education, there

         is no full-time Core staff member who is responsible for the  coordination






       NORTHt4ESTERN OHIO RIT SITE VISIT    -10-                 RM 00063

       of this effort.  4) The site-visitors were provided with an organiza-

       tional chart but it became clear that the listed functions are not well-

       defined and bear little relation to position titles. In fact, the impres-
       sion was that "all people do all things." 5) Finally, the Region  has
       requested support for three new administrative assistants as  a  part   of
       Core renewal; but, in fact, their functions were not as yet  defined.   6)
       The preparation of budgets is haphazard, and seems tohave  little  review
       since the same item may appear in two places - but for different amounts.
         The team was unanimous in its belief that the Program Coordinator is a
       sincere, devoted, dedicated physician who has won the admiration  of  his
       staff and his peers. He has tried to provide the leadership  that  is

       required but has not yet been fullysuccessful in doing so.
         It is evident that Core staff functions and responsibilities must be more
       precisely defined and lines of authority and responsibility must be -delineated
       niore clearly.  The present arrangement of part-time personnel in key admin-

       istrative posts is clearly unsatisfactory.
       Core Recommendation. In view of the above deficiencies, the team made the
                            following Core recommendations:  1) that a management
       assessment team visit be made to the Region; 2) that the Core renewal request
       be approved for one year only (instead of the three years requested) at the
       present level allocated to Core support ($335,200 -d.c.) and that the Region's
       request for a Core increase of $116,914 be denied; 3) that the  level  of
       future Core funding be determined following correction of the shortcomings

       that have been noted.








        NORTIIWEITERN O',IIO @ SITE VISIT          -11-           RY 00063

        Following a review of the Core activities, the  site visitors heard reports

        of the various committees and Danels establisned within this RMP.

          Dr. Madigan, Chairman, reported for the Continuing  Education  Committee.

        Continuing education activities in the Region are essentially a function

        of the Northwestern Ohio Institute for Continuing @tedical Education  which

        is now a department of the Medical School. The main  function  of  the

        committee is to assist groups in developing proposals and in the review

        of operational grant applications. The site visitors  noted  that  the

        committee did not include any individual professionally  qualified  in


        education.

          The activities of the Information Systems Study Committee  were  reported

        by Mr. Browning. Evidently their main activity to date  has  been  the

        formulation of a data catalog.

          In the Chairman's absence, Dr. Reas described the activity of the

        NominAting Committee as being essentially the replacement of members on

        the RAG.

          Dr. lannone, Chairman of the Stroke Panel, reported that  the  activities

        of the panel consisted of meeting with local medical societies (to stimulate

        interest in stroke activity), and reviewing stroke proposals.

          Dr. Black, Chairman of the Heart Reference Panel, reported objectives

        which seemed to be about the same as those of the Stroke Panel, with the

        exception of a special interest in coronary care training.

          Miss Helen Dickman, R.N., in the absence of Dr. Hanson, reported  on  the

        activities of the Cancer Panel.  This appeared to be one of the more active

        panels - the members meet outside of the Toledo area; they have established

        a subcommittee to explore needs in other areas; they publish a cancer news-





         ',IORTHWESTERN OflIO PIIP SITE VISIT     -12-           RM 00063

         letter; they are working with the pathologists in a slide survey; and

         they review proposals.
           Dr. Reas reported that on the activities of the Reference Panel on
         Related Diseases. The activities of this panel have been focused  on  the
         development of a multiphasic screening proposal which is to be  submitted

         to the RAG in the near future.

           The site visit team took special note of the fact that the  committees
         and oanels in this Region are composed mostly of members from the Toledo area,
         with some minor representation from the Lima and.Sandusky communities.

           The next order of business was to review the  six projects which are
         currently funded in this Region.  In spite of the criticism leveled at the
         Core staff, the team was impressed with both the enthusiasm and substance
         exhibitied during the verbal presentations (as contrasted with the written
         reports) on four of the projects. These were: #1 - -Stroke Education;  #2
         Uterine Cancerz #4                           #6 - Action on Smoking and Health.
         Here again, the Core staff was tried and found lacking in that several of
         the Project Directors spoke of their futile efforts to obtain  assistance

         in the evaluation and regional coordination  of the projects.
           In spite of reservations about Core planning and the consistent  over-
         budgeting during the first year of operation of these four projects  (and
         the Dial Access Tape Library Program as well), the evidence of  progress
         was sufficiently persuasive that the team recommended the projects listed

         above be continued.

           Finally, the team heard a report on Project #5
         R                  This project was funded for one year  (7/l/69-6/30/70)

         as a feasibility study. Approximately 15 patients have been seen  on  an

         0
          utpatient basis since the inception of this project.  The project personnel





        NORTHWESTEPJ\' OHIO PIIP SITE VISIT  -13-             RM 00063

        are obviously experiencing difficulties with the hospital administration

        in terms of equipment, payment for care. etc.  T,ie Region estimates an
        unobligated balance of $112,000 (total costs) out of the original  award

        of $144,000.

         The site visitors found such serious deficiencies in the  planning  and
        leadership of this grant as well as in its first year of operation  that

        it  is recommended the project be terminated at the end of the present


        year.


                                                  sit.

        #13 - @o                            The site visitors spent a great deal of

                                            time in discussing this ambitious
        proposal with the prososed Project Director, Dr. Iannone, who, incidentally,
        is supported by Core funds ($10,000 per year) as Chairman of the  Stroke
        Reference Panel.  After a review of the program, a consensus was reached
        that this program is premature in that: 1) the Maumee Valley Hospital
        (@ledical School teaching hospital) is not presently in the stage of
        development which will make it possible to carry out this type of program -
        even if the requested equipment should be provided; and 2) the  existing
        stroke personnel and facilities in the Region are not being fully utilized.
        Although the team was in agreement that development of such a program should
        be encouraged, they shared with technical reviewers the conclusion  that
        this program should not be funded at this time.  Instead the proposed project

        director should be urged to conduct further planning discussions.




         NORTHWESTERN OHIO RMP Site Visit          - 14 -              RM 00063
                                                                 n regard to this
                                                                                             ,@7
          some of the specific concerns needing clarification i
         proposal were:  1) better identification of sources of patient material;
         2) identification of need for A comprehensive stroke program in tire  Region;
         3) relation of this facility to  facilities already existing; 4) an exploration
         of cost-sbaring with other age-acies; 5) a commitment should be obtained
         from the medical school, stating how much of an anticipated $3,000,000
         (to bring the hospital up to community hospital standards) would be
         apportioned to the proposed stroke unit; 6) better  delineation  of  project
         director's time with regard to project, RMP, hospital, and teaching
         responsibilities; 7) detailed listing and justification of equipment;
         8) concrete evidence of support from the medical community;  and  9)  phase-

         out plans.
         Recommendation.  Nonapproval - return for revision.  In arriving at this
                          recommendation, the site visitors believed that the
         applicant should be encouraged to continue planning and  perhaps  recast  the
         proposal in a modified form, including much more specific information

         and detail.
         #14 -                                             icians. The  site  visitors
                                                                    were convinced
         that this proposal may act as the catalyst to bring about  a  more  concerted
         continuing education program to replace  the  present  scattered  continuing
         education endeavors now existing within the Region.  The proposed project
         director advised the team that cooperative  arrangements  had  already  been
         made for the program via the Medical College, the County Medical Societies,
         Heart Association, the Cancer Society, and others.  As a part of the program,
         it is planned to assemble a profile for each  practicing  physician  in  the
         Region (reading habits, materials, etc.).







         NIIRTIIWI"@STFRN OIIIO RMP SITE VISIT  -15-            RM 00063

          The three phases of the program are: 1) to develop techniques  for
         continuing education based on physicians' anticipated needs; 2) to provide
         continuing education counseling with hospitals and medical societies,  with

         the ultimate aim of developing meaningful educational programs and providing

         individual counseling to physicians in remote counties (a clinical trainee-
         ship program is envisioned); and 3) to provide continuing education workshops.

          Discussion of planning, implementation and evaluation did give site visitors

         much confidence that the proposal represented more than fond hope.

          The site visitors acknowledged the accuracy of the  commentary  of  the
         Continuing Education and Training Panel, but expressed the opinion that

         this Regi.onis making a sincere effort in continuing education.  It  was
         believed that more planning time is needed in order to answer some  of  the

         questions raised regarding specificity.

          Because Proposal #16 -                                              for

         Physicians - is similar in -,oals and objectives to this proposal, t e  two

         were reviewed simultaneously. It was a matter of some  concern  that  these

         overlapping projects in which identical personnel were budgeted in both

         and no real hint was provided of interrelationships or  relationship  to

         other continuing education programs should appear in the  same  package.

         Recommendation. Approval for one year as a feasibility study, not  as  a
                         part of core, in an amount not to exceed $75,000  (d.c.)  -

         and further, that the programmatic elements of Proposal #16 be merged with

         this proposal.

         #15   Council for Continuing Education -

               Educational Programs for Health Professionals of the Ottawa Valley Area.

          his proposal is sponsored jointly with the Ohio State Regional Medical Program

         which had submitted an identical project for consideration during, the



        NORTHWESTERN OHIO PM SITE VISIT           -16-         Rm 00063
        Febru;iry/March review cycle.  It was stated that the responsibilities
                                                    red by both Regions. only the
        and objectives of the project were to be sha
        Northwestern Ohio proposal was considered during the site visit.
           This proposal was presented to the site visitors by one of its prospective
        coordinators, Dr. William Collins (wlic@ is also the Chairman of the RAG for
        NWOIUT), and by a representative of the Ohio State @T.  The team was told
        that this is a request for funds to support continuing medical education
        activities, primarily in the Lima area.
           In applying for the grant, the proposers believed that it would serve

         the following purposes:
           1) Generate enthusiasm for a'program to be sponsored locally.  Dr. Collins
              related an example of a drug abuse education program which had almost
              100% cooperation and attendance by the physicians in the Lima area.
              This type of activity was considered to be an excellent method of
              cementing liaison within this group.
            2)Involve all health professionals in a planned educational program.
            3) Encourage subregionalization and utilization of what is already

              available in the Region.
            4) Serve as an aid in the recruitment and training of health personnel.
            5) Coordinate with Comprehensive Health Planning activities.
            According to the applicant, educational programs in the past have usually
           been held in Toledo.  These programs have not been well supported by Lima
           professionals because of the distance involved.@
            The Ohio State RMP representative, Mr. Braxton Tewart, reported that these
           cooperative efforts can only serve to strengthen each Region.  He also told
           the team that a preliminary progress report had been prepared for an
           identical p                    n in operation for almost one year in
                     roject, which has bee

           Springfield, Ohio.




          NORTH@4ESTERN OHIO RMP SITE VISIT         -17-             RM 00063

           The site visitors believed this to be a planning effort which could

          easily be related to Project #14 - Continuing Education for Physicians,

          for which the team has recommended partial funding.  Therefore, in view

          of the Advisory Council's deferral decision regarding  funding  of  additional
          projects (a project in Springfield, Ohio, OSRNP, has been funded, and a
          second project, in the Portsmouth area, was recommended for  approval),  they

          were reluctant to recommend approval of additional  similar  projects  until

          such time as evidence of satisfactory progress on thf@ ongoing projects

          has been presented.
           @lembers of the site visit team recommended deferral in  view  of  Council's

          decision. However, they believe the record should  indicate  that  they  were
          greatly impressed by the enthusiasm and the obvious local  commitment  to  the
          objectives of this proposal.  Also, the team believed that the Region should
          be encouraged to include some of the elements of this proposal as  a  part  of
          Project #14 - Continuing Education Feasibility Project, if their partial

          funding recommendations of this project is accepted.

          Recommendation.  Deferral, pending Council decision.
          Project #17 - "Patient Problem Oriented" Education  Program  for  Professional

                        Nurses and Allied Health Personnel.  The  site  visitors  were

          aware that this was a revision of a proposal which  was  originally  reviewed

          during the November/December 1969 review cycle and was recommended for

          nonapproval - revision requested.
              The site visit team was impressed with the amount of pre-program planning

          efforts which have already gone into this proposal.  The activities are
          supported by large planning committees composed of  representatives  of  all

          health personnel in four subregional areas.
            This proposal has evolved under the leadership of the two  nurses  on  the

          core staff.





        NORTHWESTERN OHIO @ SITE VISIT           -18-          RM 00063
          The team was presented with workshop evaluations on two educational
        programs which have already been presented   one in Lung Cancer and one

        in Care of t     ed.
          The site visitors had many questions regarding the actual types of
        educational presentations to be made - for example, "patient problem
        oriented'@ urban versus rural programs.  Also, the team believed that the
        proposed evaluation system needs strengthening and that there was a lack
        of documentation of support from the Allied Health Professions  other
        than nursing.  However, they were convinced that the program should
        receive some support because of the progress and momentum already
        achieved.  It was thought  that this proposal may develop into the
        Region's first example of a truly regionalized program, through its
        subregional committees and interprofessional aspects.
        Recommendation.  Approval as a feasibility study, not as a part of core,
                         in an amount not to exceed $50,000 (d.c.) per year for

        each of two years.
          The final act of business of the site visit was a meeting (closed session)
        of the entire team with the Program Coordinator.  The meeting afforded an
        opportunity for the site visitors and the Program Coordinator to review
        and discuss the findings of the team, especially in regard to Core and

        the administration of the Region.




           @4OR'I'RWFS'CERN 01110 Rt4P SITE VISIT   - 19-            RM 00063

                           STJMMA-RY 01@' RECOMM@,NDATIONS OF SITE VISITORS


           ON CURRENTLY FUNDED PROJECTS


           Project
           Number       Title                              Recommendation

           00           Core                               1) that a management assessment
                                                              visit be made.
                                                           2) that Core  renewal  be  approved
                                                              for 'one @ar  only  (instead   of
                                                              the three  years  requested)  at
                                                              the present  level  allocated  to
                                                              Core support ($335,200) and that
                                                              the Region's request for a Core
                                                              increase of $116,914 be denied; and
                                                           3) that no funds  be  committed  for
                                                              Core activities  for  the  second
                                                              and third years.
           1            Stroke  Education  Program         *Second-year    continuation

           2            Uterine  Cancer  Detection         *Second-year    continuation

           4            Coronary Care TrainLR              *Second-year    continuation

           5            Improvement of Respiratory         Denial of  the  extension  request.
                         Care                              Project to be terminated as
                                                           of 6/30/70.

           6            Action on Smoking and Health       *Second-year    continuation

           7            Dial Access  Tape  Library         *Second-year    continuation

                *In these recommendations Staff  is  cautioned  to  exercise  careful  judgment
                 (in view of the findings of the team regarding Core) in awarding any
                 unexpended first-year funds, to permit increases for these individual
                 projects during the second operational year.
           ON PROPOSALS DEFERRED FOR SITE VISIT BY  ACTION  OF  MARCH  1970  ADVISORY  COUNCIL

           13                                              Nonapproval -  return  for  revision
           14           Program for Continuing             Approval for one  year  only  as  a
                        Education  for  Physicians         feasibility study, not  as  a  part
                                                           of core, in an amount not to
                                                           exceed  $75,000  (d.c.).   Further,
                                                           that the  programmatic  aspects  of
                                                           Project #16 (to be described below)
                                                           be merged with this proposal.

           1.5          Council for Continuing             Deferral, pending Council decision.
                        Education - A  Project  to
                        Develop Organized Educational

                        of the Ottawa Valley Area




          NORTHWESTERN OHIO @ SITE VISIT             -20-           RM 00063

          SIIWIARY OF RECOMMENDATIONS ( ontinued
          PROPOSALS SUBMITTED  FOR  J@E/JULY  REVIEW  CYCLE

          Project                                         Recommendation
          Number      Title
                      A Program in Continuing Medical     To be merged with Project #14
                      Education  or Phvsicians            (described above).
          17          "Patient Problem oriented"          Approval as feasibility study
                      Educationa  Prop-ram for            (not as a part of Core) for two
                      Professional Nurses and             years in an amount not to exceed
                      Allied Health Personnel-            $50,000 (d.c.) per year for
                                                          each of two years.
          SUMMARY OF                                               MENDED BY THE
          SITE VISIT TEAM


          Project
          and Title                     Amo             ed (d.c.)      Amounts Recommen ed (dc-)
                                     lst Year  2nd Year  3rd Year     lst Year  2nd Year  3rd Year

          14          ram For
                                     $110,926 $112,156  $116,070


          16          ram in

            Education for Physicians
                                     $ 69,825 $ 61,028  $ 63,609

          Totals of Projects
            -#14 and #16             $180,751 $173,184  $179,679     $ 75,000    None       None
                                                                      (as a feasibility study
          Three Year    total - $533,614                               not to be included as part
                                                                       of core)

          17 - "Patient Problem
            Oriented" Educational
            Prop-ram f r Professiona-L
            Nurse s and Allied Health
            pers onne 1              $1 11,146 $100,803  $104,180    $ 50,000  $50,000
                                                                      (as feasibility study
          Three Year total     $316,129                               not to be included as
                                                                       a part of Core)

                                                          TOTALS      $125,000  $50,000















             0                                                              0                                                              0









                              REGIONAL MEDICAL PROGRAM SERVICE
                  SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                  (A Privileged Communication)


             Ohio State Regional                                        RM 00022 7/70.1
             Medical Program                                            June 1970 Review Committee
             1480 West Lane Avenue
             Columbus, Ohio  43221

             L'iLo@@m_Coordinator: William G. Pace, M.D.

             Lr   ram
             Period
                  e3t          Ist  Year     2nd  Year     3rd  Year      TOTAL

             Direct Costs       $761,935      $877,488      $961,852       $2,601,275
             Indirect Costs      176,133       208,507       233,157          617,797
                TOTAL           $938,068    $1,085,995    $1,195,009      $3,21.9,'072


                      The Region received  a  one-year  planning  grant  beginning
                      April 1, 1967 which was  extended  through  June  30,  1968
             to allow time for preparation of a competing renewal grant.  A second-
             year planning grant was awarded July  1,  1968  for  a  total  $1,031,479
             of which $569,267 supported four one-year feasibility studies, $331,891
             supported the core, and $130,319  was  awarded  for  indirect  cost.
             Following a preoperational site  visit  in  December  1968  a  first-year
             operational award was made effective  May  1,  1969  which  provided
             fourteen-month support for  Core  and  nine  projects.  Since  May  1969
             three operational supplement applications consisting of twelve
             projects have been  considered  during  the  intervening  review  cycles.
             'I'lie star-us of approved and funded projects as well as those unfunded
             is outlined on the attachments to this summary.  Review of the
             Regions'Ol year  non-competing  application,  for  continued  support
             of the operational projects, will be reviewed  by  staff  in-  June.
             William G. Pace M.D. replaced Neil  C.  Andrews  as  Coordinator  as  of
             2/l/70.

             Present Application
             This application consists of  two  projects;  Core  which  is  requesting
             renewed  support and Project #24 - Continuinp, Education of Allied
             Health Professionals.
                                                                                 Requested
             Core                                                                First Year@
             Three years support is being requested to expand and continue       $697,501
             staff operations which consists of the Office of the Coordinator,
             The Division of Continuing Education, The Division of Field Relations,
             The Division of Public Information, The Division of hospital Relations,
             The Division of Manpower and the Division of Evaluation.





             Ohio State Regional                                          00022    7/70.1
             Medical Program                      2


             Support is  requested  for  twenty-three  full-time  and  five  part-time,
             25% - 50%, professional and paraprofessional positions, plus fourteen
             full-time  supportive  staff  positions.  This  represents  an   addition,
             over the number of positions approved for the current year, of ten
             full-time and three part-time professional and paraprofessional
             positions, and two full-time supportive staff positions.  The applicant
             does not identify specifically the  new  positions,  and  it  is  of  little
             value to attempt  such  identification  by  comparing  the  positions  being
             requested to those approved for the current year, since positions
             and titles have been  changed  to  correspond  to  sub-divisions  of  Core
             which have been altered.
             Following is a comparison  of  budget  categories  for  the  current  year
             and the requested year.
                                                          70   7/l/70 - 6/30/71

             Personnel                       $250,097               $521,176
             Consultants                      15,450'                30,400
             Equipment                        38,100                 11,450
             Supplies                         12,000                 29,000
             Travel                           34,658                 46,350
             Sub-Contract                     100,000                  0
                                         (rebudgeted from Personnel)
             Publications                     20,000                 30,000

             Other                            27,525                 29,125
                                             $497,830               $697,501


             It should be noted  $38,605  of  the  requested  increase  in  personnel  is
             attributed to an annual 8% salary increase.
             The Regional Advisory Committee which has broad organizational representation
             consists of 38 members of which 28 are from Columbus and nine are
             attached to the University.  Consumer and minority group representation
             is  not  identified.  RAC  operating  policies  are  presented.  A   major
             accomplishment of the RAC during the past year, as cited by the
             applicant, has been its metamorphosis from a body which reviewed
             and passed  upon  operational  projects  to  a  coordinated  working  body
             which has taken a specific interest in goals, objectives and policies.
             A steering committee composed of a cross section of RAC members has
             been  formed  and  its  responsibilities  are  defined.  Four  Task  Forces,
             Heart Disease, Cancer, Stroke and Hospital Services, have been organized
             and are actively involved in initiating and reviewing proposals.  Local
             planning committees have been formed in the fourteen subregional planning
             areas identified within the Ohio State RMP.  It is stated that during the





            Ohio State Regional               -- 3 -             RM 00022  7/70.1
            Medical. Program


            past year, a number of LPCs have moved from "paper" committees to
            very active, dynamic groups, supporting evidence is based on a few
            examples.  Attempts have been made, through meetings with various
            personnel of'the Comprehensive Health "A" and "B" Agencies, to develop
            working relationships.  Specific accomplishments of these meetings
            is not identified.  Neither agency is represented on the RAC.  An "Action
            Cycle" is presented outlining the steps to be followed from the creation
            of an idea to the final proposal and its review.  Activities for the
            past year are presented for each of the Core subdivisions.  With
            slight shifts in emphasis, program plans for the future are based
            primarily on continuing and expanding present activities.
            General plans for program and project education are presented.
            Second Year: $746,300                    Third Year: $803,130

                                                                     Requested
            Project #24 - ContinuinR Education for Allied Health     First Year
                                ionals. This project is sponsored    $64,434
            by the School of Allied Medical Professions of the Ohio State University
            Its purpose is to plan, develop, implement and eval-uate ongoing continuing
            education program for allied practitioners, administrators, and
            educators in the region.  The primary focus will be on multidiscipline
            programs and team learning, and the approach will be patient centered.
            Specific objectives are:  1) to assess the needs of practitioners
            and educators by comparing optimal delivery of health care services
            with what now exists, 2) to devel-op relevant uiultidisciplined continuing
            education programs for the allied health professions, 3) to implement
            these programs, utilizing various methods and techniques, 4) to evaluate
            the effects of the multidisciplined programs upon health personnel
            and patient care, and 5) to compile and report the findings.  The
            program will be implemented in three phases.  Phase I, the first nine
            months of operation willbe precruitment planning and development
            phase.  Phase II, a twelve-month period, will be a full operational
            phase in which the committed schedule of major programs, including
            six programs at Ohio State and six programs in local areas, wil-1
            be planned, implemented and evaluated.  Plans also include the production
            and broadcast of two programs over the TV/two-way radio network.
            Phase III, a second twelve-month period, will be an extension of
            Phase II with further modifications and refinements, and the final.
            tiiree-year evaluation completed.  Approximately twenty programs will
            be scheduled of which six will be adapted for sub--profoissionals and
            ancillary personnel, e.g., associate degree people, technicians and
            aids. Also during this phase, a report will be published of the project
            and its findings, and financial support will be secured for continuation
            of the project.  Plans for evaluation are both process and product
            oriented. Basic items of the budget are:  Personnel, $36,004; Consultant
            Services, $6,000; Equipment, $6,080; Travel, $7,250; and other, $5,000@
            Second Year: $131,188                         Third Year: $158,722





           Ohio State Regional
            Medical Program                   - 4 -             RM  00022  7/70.1


           SUMMARY OF OPERATIONAL PROJECTS CURRENTLY BEING SUPPORTED

                                                       Approved            Funded 01 Year
           Project Title & Number                      Project              (direct cost)
                                                       Period              5/l/69 - 7/l/70

                 CORE                                     1                     $497,830

           #2 - Coronary Care Unit Education              3                     $120,590

           #3 - Rehabilitation Training for
                 Health Professionals                     2                      $56,557

           #4 - Careers in Health Science Program         2                      $22,227

           #6 - Sudden Death:  Mobile Coronary            2                     $150,937
                 Care

           #8 - Computer-Assisted Instruction             1                     $229,292


           USE OF UNEXPENDED FUNDS WAS APPROVED FOR THE FOLLOWING PROJECTS

           #7 - Critical Data Base                                               $90,085

           #6 - Sudden Death: Mobile Coronary                                    $11,020
                 Unit - Supplement

           #9 -  InvestiRation  of  Situational  Conditions                      $10,965
                in Hospitals Affecting Continuing Education
                Programs for Allied Health Personnel
                  (additional under Core)
          #11 - Council on Continuing Education - Springfield                    $37,468

                                                               TOTAL           $1,226,971



           SUMMARY OF UNFUNDED PROJECTS

           Project Title & Number                                               Status

           #1 - Videotaped Educational Materials for Stroke Patients and
                 their Families                                              Disapproved

           #5 - Multivariate Study of  the  Career  Development  of  Potential
                 Heart Professionals                                         Disapproved

          #10 - Ohio Cancer  Data  and  Instruction  Center                  Return for Revision

          #12 -                                               for            Return for Revisic',@
                 for Primary Ph_ys cians
          #13 - Trai            clinicians                                   Disapproved






            Ohio State Regional.
             Med,'J'Lcal Program                - 5 -                    RM 00022 7170.1


            #14 - Council for C            Education - Portsmouth             Disapproved

            #15 - Central Ohio Phonocardioscan Screening                      Approved
                                                                          (with contingencies)

            #16  - Council for Continuing Education - Mansfield               Disapproved

            #1@7 - Nutrition Education                                        Disapproved

            #18  - A Comprehensive Continuing Education Program
                    fo r Primary Physicians (revision of project #12)         Return  for  Revision

            #19  - Videotaped Educational Materials for Stroke Patients       Return  for  Revision
                    and Their Families (revision of Project #1)

            #20  - A Proposal to Screen School Age Children for Heart         Return  for  Revision
                    Ailments with Phonocardioscan


            #21  - Continuing Education on Early Detection of Oral
                   Malignancy                                                 Return  for  Revision

            #22  - Council for ContinuingEducation - Ottawa Valley            Disapproved

            #23  - Continuing Education for M.D.s and RNs in Management       Return  for  Revision
                    of Acute Stroke


            #7R  - Critical Data Base                                         Approved for
                                                                               3 Years


            #8R  - Computer-Assisted Instruction                              Site Visit
                                                                              Return to 7/70
                                                                              Review Cycle









                                                                   @S/GRB/7//3/70






















        ,,@ 0                                                              0                                                              0








                                  REGIONAL MEDICAL PROGRAMS SERVICE
                       SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                       (A Privileged Comunication)

           OHIO STATE REGIONAL MEDICAL PROGRAM                          RM  00022  7/70.2
           1480  West  Lane  Avenue                                     June 1970 Review Committee
           Columbus,   Ohio   43221

           Program Coordinator:    William G. Pace, M.D.
           .Requested           lst  Year          2nd   Year      3rd Year            TOTAL
           Direct Costs         $389,758           $706,804        $295,599            $1,392,161
           Indirect Costs         46,771               84,816                           167,059


           TOTAL                $436,529           $791,620        $331,071            $1,559,220

           NOTE:  Although the detailed budget     requests  only  one year of   support,
           the Region indicates that this is a     three year proposal.  Costs for the
           second and third years will approximate those described in the original
           application.

           HISTORY:  For  history  see   application   7/70.1

           Background  of  Present  Application:  This  application  consists  of  one   project,
                                                   #8R  -  Computer  Assisted  Instruction  in
           Meeting Information Needs of Local Community Health Practitioners. This is a
           proposal for  renewal  and  expanded  support  for  further  development  of  computer
           Assisted Instruction as a  means  of  meeting  the  information  needs  of  local
           community  health  practitioners.  The  project  was  originally  supported  as   a
           one-year feasibility study ($241,360).  During this time a three-year
           operational proposal was submitted, approved and funded at $229,292 for only an
           additional 14-month period (5/l/69-6/30/70).  In order to provide continuity
           of support to  the  project  after  6/30/70,the  Region  submitted  this  renewal
           application for consideration during the 3/70 Review Cycle.  However,
           Committee recommended  it  be  deferred  pending:  1)  Council  Action  on  policy,
           and 2) a site visit.

           Comittee's remarks in  the  February  1970  Review  were  for  the  most  part
           favorable.  However, it was observed that the evaluation originally planned
           for this proposal was practically nonexistent in the application.  Staff in
           response  reported  that  comprehensive  evaluation  addendum  had  been   received
           which covers  several  types  of  evaluation  techniques  designed  to  determine
           knowledge impact through use  of  CAI  as  well  as  attitudual  data  towards  its
           use.  Committee accepted Staff's opinion that the report represents a
           significant contribution to  the  knowledge  of  the  usefulness  of  CAI  for
           health professionals and that it answers quite satisfactorily questions raised
           in earlier reviews.  Committee  expressed  concern  that  since  CAI  is  in  the
           experimental stage,  that  projects  involved  in  such  activities  might  be
           classified as research  and/or  development,  which  is  not  a  function  of  RMP.
           It was believed that policy  needed  to  be  established  and  was  so  requested
           of Council.  It was further recommended, that in view of CAI activities
           being relatively new  to  RMP  and  Committee's  admitted  lack  of  knowledge
           regarding its' effectiveness, a site visit should be made to the program
           and reported back to committee.






          Ohio State RMP                      -2-                 RM 00022 7/70.2


          May Council accepted the substance of the proposed Instructional Techno-
          logy Policy but suggested a rew-@ite for clarification of terminology.  This
          policy states that since CAI is in the experimental stages, RMP should
          look at CAI projects with caution in respect to total dollars invested
          and further evaluation as a continuing education tool.

          A site visit will be conducted in early June 1970.


                                                                       Kequested
                                                                       First Year
                                                                       $389,758
          Present Application
          Project #8R - Computer Assisted Instruction in Meeting Information Needs
                        of Local Community Health Practitioners.  The information
          presented in this application reflects the progress accomplished during
          the last year with little information on future objectives.  Progress
          has been made in determining how quality CAI materials can be produced
          and an increase in the cost--sharing of system users has been established
          to assure support after a three-year peri@d.  The project has been altered
          to include 10 hospitals rather than the 30 proposed and a total of 5 courses
          were produced including four dealing with the categorical diseases.  Relation-
          ships with several other RMP activities are described.  During the past
          year, several of the individuals assigned to the project have accepted other
          jobs and are no longer in a position to continue working on the project.
          The goals and objectives are apparently the same as those described in
          the original three-year proposal.

          Second Year: $706,804                          Third Year:   $295,599
























                                                                    DRMP/GRB 5/26/70





                                                                        A Privileged Conanunication)


                                SUMMARY OF REVIEW AND CONCLUSION    OF
                                    JUNE 1970 REVIEW COMMITTEE


                               OHIO STATE REGIONAL MEDICAL PROGRAM
                                      RM 00022 7/70.1, 7/70.2

                         FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL



              General:  Two  applications  7/70.1  and  7/70.2  requesting  support  for
                        -Core and  two  projects  were  considered  by  Committee.  One
              project #8R - @om     er Ass-L.,,-ted Instruction in Meeting  Information
              Needs of Local Community Health Practitioners had been deferred during
              the March 1970 Review Cycle  for  a  technical  site  visit,  which  was
              conducted in  June  1970.  The  team's  findings  and  recommendations
              were available for the Committee  reviewers.  As  a  resul.t  of  this
              Committee Review, Core and  Project  8R  were  recommended  for  approval.
              but pro'ect #24 - Continuing Education for Allied Health Professionals
                     i
              was returned for revision.


              Core
              Critique:  Committee  observed  that  the  Regional  Advisory  Committee
                         has  broad  organizational  representation  and  consists  of
              38 members with 28 from Columbus and nine from the university.
              Consumer and minority group representation seems weak.  The application
              cites   that'a major accomplishment of  the  RAC  during  the  past  year,
              was its metamorphosis from a  body  which  reviewed  and  passed  upon
              operational projects to  a  coordinated  working  body  which  has  taken
             .a specific interest in goals, objectives and policies.  A:
              Steering Committee composed of  a  cross  section  of  RAC  members  has
              been  formed  with  defined  responsibilities.  Four  Task  Forces,  Heart
              Disease, Cancer,  Stroke  and  Hospital  Services,  have  been  organized
              and are actively  involved  in  initiating  and  reviewing  proposals.
              Local. planning committees have been formed in the fourteen subregi.onal
              planning areas identified within the Ohio State RMP, and the
              Region believes that A  number  have  moved  from  "paper"  committees  to
              very active, dynamic  groups.  Attempts  have  been  made  to  develop
              working  relationships  with  various  personnel  of  the  Comprehensive
              Health "A" and  "B"  Agencies,  however  neither  agency  is  represented
              on the RAC.' An "Action Cycl.e"  is  presented  outlining  the  steps  to
              be followed from the creation of an  idea  to  the  final  proposal  and.
              its review. Activities of  the  past  year  are  presented  for  each  of
              the Core subdivisions.  With slight shifts in emphasis, program
              plans for the future are based primarily on continuing and expanding
              present activities.  Ceneral plans for program Pnd project evaluation
              are presented.

              The Committee was favorably impressed with the achievements and
              future plans of the Core activity, but felt that the Region has
              failed to justify the need for the big increase requested for cor@ suDDort.
              The budget requested for porsonTie'L,represents  a  1.00%  increase  over
              the current years funding.  The Committee believes that somc@. increased





             OHIO State PIT                      2               RM 00022 7/70.1  &  .2

             support is needed to accomplish   their goals.  The Committee recommendation
             is to increase the support for Staff over the current level by approximately
             50% the first year, 75% the second year and 100% the third year.

             Recommendation4  Approval I - at a reduced level.

             01 Year:  $469,119          02 Year: $529,960         ,!03 Year:  $589,380

             Project #24 - Continuing Education for the Al.lied Health Professionals.

                         Both Committee and the Continuing Education and Training Panel
                         found it difficult to evaluate this proposal.  Phase I is
             .addressed essentially to planning for programs  in  continuing  education
             for allied health. Why the Region  has  not  already  undertaken,such
             planning activities with Core funding is  not  explained.  The  planning
             process described is good, provided the staff  capabilities  are  adequate.
             The Committee recommends that an application for  funding  be  submitted
             for Phases II and III, after additional- planning has  been  conducted
             with Core funds.


             Recommendation:  Non-Approval II - Revision Required.

             Project.#8R - Computer Assisted Instruction in  Meeting  Information  Needs
                            of Local Community Health Pract'tioners

             Critique: Committee considered  the  site  visitor's  recommendations
                         as follows:


                  1.  The potential appears to exist at OSU, but if  RMP  wants  a
                      satisfactory trial of CAI, adequate time  should  be  allowed
                      and the project monitored yearly to insure that the desired
                      outcome is obtained.


                  2.  The emphasis on the project should move  from  the  technical
                      aspects of the development of the CAI hardware and software
                      to the Development and application of instruction and
                      evaluation. Evaluation should  include  references  to  support
                      from sources other than RNP and use  of  PAS-MAP  statistics
                      or other data to evaluatethe effect of proble@oriented
                      CAI on morbidity and mortality, etc.

                  3.  The project should not be expanded  to  additional  hospitals
                      until the above is well underway.   It is not practical to extend
                      the network until a larger number of  more  patient-care  directed
                      programs are developed, since the physicians  and  nurses  in
                      hospitals now;usi-ng the service have stated that present courses
                      were not the most practical.  In fact, proper evaluation techniques
                      may prove more effective if fewer  hospitals  are  used.  However,
                      the site visitors did -not recommend dropping  any,  for  obvious
                      public relations reasons.

                  4. There should be a full-time project dii7ector; Dr.  Ertel-,  the
                      current part-time director' seems very competent  to  handle  the
                      responsibility.




                                                 3                   RM 00022 7/70-1. & .2
              Ohio State RMP


                     5. RNPS staff should provide close scrutiny of yearl.y   progress
                        reports, with a site visit if necessary, to insure    that better
                        patient care evaluation techniques are being developed  and
                        employed. The site visitors realize that it  will  probably
                        take three more years to evaluate adequately the effectiveness
                        of the CAI approach.

                     6. RMP funds should not be used to  pruchase  a  computer  in  the
                        second  year.  Time-sharing  arrangements  should  be  possible
                        with all of'the computer resources available to the project.

              The Committee discussed the potential value of CAI and decided that
              the investment and potential in the OSU project was worthy of continued
              support, but not at the level requested.

              -The two technical site visitors were unable to agree on an appropriate
              amount fcrcontinuation of the project (the technical expert suggested
              $100,000 and the education specialist $192,000).  Committee decided on
              an arbitrary figure of $160,000 for each year.

              Recommendation: Approval I - At the reduced  level  of  $160,000  a  year
                              for each of three years, with two conditions

                     l.'The project should not be expanded to additonal hospitals
                        until the emphasis on the  project  moves  from  the  technical
                        aspects of development of CAI  hardware  and  software  to  the
                        development and  application of instruction and evaluation.

                     2. A full-time project director be appointed.


                                   SBMARY OF RECOMMENDATIONS

         Proiect Title &              Recommendations         01         02       03      Total
              7/70.1                  Approval. I
         CORE                         At Reduced Level      $469,119 $529,960 $589,380 $1,588,459

         #24 - Continuing             Non-approval II
         Educ t@oii--f@Al:lied-       Return for Revision               -O-       -0-      -0-
         Health   Professionals


              7/70.2
         #8R      @C@t@er             Approval I    At a
         Assisted   Instruction       Reduced Level          160,000  160,000  160,600  480,000
         in MO    n  @ format o@n     With Conditions
         Needs of Local Community
         Health   Practitioners
         TOTAL APPLICATIONS           Approved with        $629,119 $689,960 $749,380 $2,068,459
           7/70.1 & 7/70.2            Conditions






                                                              A Privileged Communication
                                   SITE VISIT REPORT          RM 00022
                          OHIO STATE REGIONAL MEDICAL PROGRAM
                                     Columbus, Ohio

                                       June 4, 1970



             SITE VISITORS:

             Joseph W. Hess, M.D.
             Director, Office of Research in Medical Education
             Wayne State University
             School of Medicine
             Detroit, Michigan

             Jay Wakefield
             Project Coordinator
             Medical Computer Service Project
             Washington/Alaska RNP
             Seattle, Washington




             Dona E. Houseal
             Public Health Advisor
             Grants Review Branch

             PROJECT SPOKESMEN:
             William G. Pace, M.D'.                           Paul Y. Ertel, M.D.
             OSRMP Coordinator                                Associate Professor
             Columbus, Ohio                                   Department of Pediatrics
                                                              OSRMP-CAI Consultant
             Gerald W. Gast6ft D.D.S.                         Children's Hospital
             OSRMP-CAI Project  Supervisor                    Columbus, Ohio
             The Ohio State University
             Columbus, Ohio                                   John A. Prior, M.D.
                                                              Associate Dean
             James V. Griesen                                 College of Medicine
             Associate Project Director@OSRMP-CAI             The Ohio State University
             Acting Director, Division oi@Research            Columbus, Ohio
                and Services
             The Ohio State University College of             Gregory Trzebiatowski, Ph.D.
                Medicine                                      Assistant Dean for Medical
             Columbus, Ohio                                      Education Development
                                                              College of Medicine
             Mrs. Sally Navin, Ph.D.                          The Ohio State University
             Associate Project Supervisor                     Columbus, Ohio
             The Ohio State University
             Columbus, Oh io





           OHIO STATE RNP Site Visit         2 -                Rm 00022

           Mrs. Juliana Hushak                             Lewis A. schmidt, M.D.
           Systems Programmer                              Surgeon and
                                                           Course-Author - OSMP-CAI Project
           OSRMP-CAI Project
           Columbus,  Ohio                                 The Holzer Medical Center'
                                                           Gallipolis, Ohio
           Mrs. Rosa M. Hartsook, OTR
           Consultant,to OSRMP-CAI Project                 Robert D. Berger, D.O.
           for Occupational and Physical The-rapists       Medical Director
           Columbus,  Ohio                                 Grandview Hospital
                                                           Dayton, Ohio
           Mr. Samuel Morrison
           Systems Analyst                                 Mrs. Barbara Betz, R.N.
           OSRMP-CAI Project                               Assistant Director of'Nursing
           Columbus,  Ohio                                 The Holzer Medical Center
                                                           Gallipolis, Ohio
           Robert C. Ringe, Ph.D.
           RMP Staff Liaison to OSRMP-CAI
           Director of Public Information OSRMP
           Columbus,  Ohio







            OHIO STATE RMP Site Visit          - 3                           RM 00022


            The  site  visit  was  convened  to  review  the  Computer-Assisted   Instruction
            Project  of  the  Ohio  State  Regional  Medical  Program.  The  project   has
            been  supported  since  May  1968  and  was  submitted  for  renewal  during  the
            February-March  1970  review  cycle.  At  that  time,  Committee   and   Council
            recommended that  a  site  visit  be  held  to  assess  the  project's  effective-
            ness.  More  specifically,  the  site  visitors  set  out  to  review  and  deter-
            mine:
               (I) the  background  and  assessment  of  the  present  quality  of  the  proj-
                  ect and its staff;
              (II) the project's future objectives;
            (III) the  future  staffing  plans  in  light  of  recent  personnel   changes;
              (IV) future  plans  for  evaluating  the  effectiveness  of  CAI  as  a  tech-
                  nique for continuing education of health care personnel.

            I.  THE  BACKGROUND  AND  ASSESSMENT  OF  THE  PRESENT  QUALITY  OF  THE  PROJECT
                AND ITS STAFF

            Representatives  of  the  Ohio  State  University  Medical  School  and   Ohio
            State  RMP  staff  presented  some  general  information  at  the  beginning  of
            the  visit.  Dr.  Prior,  Associate  Dean  of  the  College  of  Medicine,  told
            the visitors about the pilot medical school, an independent study program
            at the medical s@hool  which  includes  CAI  as  an  integral  part  of  its  pro-
            gram.  The  OSRNP  CAI  is  using  several  of  the  medical  school's  programs,
            such  as  histology,  gross  anatomy  review  and   physiological   chemistry.
            The project also utilizes the University Computer Center.
            Staff  believes  they  have  demonstrated  the  operational  feasibility  of   a
            CAI network  which  unites  the  University  Medical  Center  to  a  number  of
            community hospitals via a computer network.  The project has gone through
            various changes  in  personnel  and  software  to  arrive  at  a  smoothly  func-
            tioning  stage.  While  the  technical  competence  of  the  staff  appeared   to
            be adequate,  project  management  may  have  been  less  than  optimal  in  the
            past. Apart from  a  number  of  changes  in  top  project  staff  in  the  last
            year,  the  leadership  of  the  project  appeared  to  be  the  responsibility
            of four people  -  Dr.  Gerald  Gaston,  Mr.  James  Griesen,  Dr.  Ayres  D'Costa
            and  Dr.  Pace,  the  OSRMP  Coordinator.  At  the  present  time,   uncertainty
            of  RMP  funding  has  led  to  reduction  of  project  staff.  However,  they
            have contingency  plans  for  holding  key  people  on  the  project  until  they
            know whether support will be continued.

            Staff  reviewed  some  of  the  technical  difficulties  they  have   overcome
            during  the  past  two  years.  The  IBM  program,  COURSEWRITER  III,  is  being
            revised to allow for analysis of student response an          ine  usage,   auto-
            matic self-registration of a large number of users under one s.ign-on-code
            and  access  to  the  domputer's  mathematical  capability.  The   system   is
            currently in  operation  22  hours  a  day,  seven  days  a  week.  The  systems
            analysts  are  still  working  with  the  problem  of  accommodating  the  hard-
            ware  and  COURSEWRITER  language  to  programs  involving  large  amounts   of





            OHIO STATE R14P Site Visit      4                       RM 00022

            information, such as listings of drug and dietary material.  Determina-
            tion of educational needs has been based entirely on the opinions of
            potential users and university personnel.  The process by which ideas
            are transmitted from hospital staffs to a computerized course has been
            reorganized twicia.  Under the latest version, a topic is selected by a
            particular hospital's Continuing Education Committee, composed of members
            of the medical, nursing, occupational therapy, physical therapy and
            dental professions.  A Principal Author, the subject matter specialist,
            sets the criteria for the course, consults with the Course-Author team,
            who are trained in CAI and concentrate on course content presentation.
            An Author-Consultant Team, composed of an educational specialist, tech-
            nical editor and input coder, then advise strategies, technically edit
            the writing and enter the material into computer memory.  The project
            presently supports two half-time Course Authors and one Author-Consultant
            Team, who would presumably be able to work with 30 to 50 principal
            authors.  Project staff believes that what they have learned about how
            to combine the skills of subject matter specialists, trained CAI authors
            and programmers will now permit more rapid production of CAI software
            during the coming year.
            Physicians and a nurse from user hospitals expressed favorable opinions
            regarding the potential of CAI in solving in-service and continuing edu-
            cation problems in their institutions.  However, they also reported that
            the currently available library of programs is too limited to have a
            major impact as yet.  Physicians stated that they would like an informa-
            tion retrieval capability built in and more problem-oriented programs
            added to the library.  Physician use has been entirely on a voluntary
            basis and no change in that practice is anticipated.  CAI is more system-
            atically encouraged and used by nursing and paramedical personnel.  The
            coronary care nurse course is being heavily used and nurses are being
            given released time to take it.  Nurses, allied health personnel and
            physicians present all stated they saw CAI as a very useful tool to be
            used in conjunction with textbooks and lectures to help train entry
            level personnel, such as operating room assistants, ward clerks, occu-
            pational therapy assistants and to review basic sciences for nurses.  As
            such, it could relieve trainers and be used as an evaluation device to
            measure the gaps in learning.
            Doctors Schmidt and Berger, Mrs. Betz and Mrs. Hartsook were questioned
            about the effect of CAI on patient care.  There did not seem to have been
            any serious attention given to this type of evaluation other than the
            work performance checklists described in the evaluation supplement.
            As far as evaluation of student usage, the proposers have data available
            on frequency of use by course in each hospital and also on student respon-
            ses during a CAI course but most of this data has not as yet been analyzed
            and incorporated into their formal evaluation scheme.









                                                                        RM   00022
           OHIO STATE RHP Site Visit      - 5


           11.  FUTURE OBJECTIVES
           During the course of the site visit, it became apparent that a change  in
           project orientation is underway. As a result of experience  gained  to
           date and feedback from users in the various hospitals, the  computer-based
           program will be adapted to the individual needs and interests of the
           various professional groups and institutions. Physicians,  for  instance,
           want more problem-oriented information, instruction and services  which
           can help them with patient management. They prefer shorter  periods  of
           time (10-20 minutes) at the terminal to obtain material which will  help
           them with specific problems. Types of courses which they  would  prefer
           are those in electrolyte problems, drug information, etc. They  are  not
           favorably disposed toward didactic type courses of an hour or more  in
           length. In response to these preferences, the project  personnel  stated@
           they are planning to develop patient management materials pertaining  to
           pulmonary disease, rheumatic fever and infectious complications of  cancer
           and stroke, during the coming year.
           Nurses have the greatest interest in coursework which will improve  their
           basic science background and help them learn nursing care  procedures.
           Occupational and physical therapy personnel have expressed the need  for'
           courses that provide information on procedures in  their  field.  They
           mentioned that the Stroke Rehabilitation Course is fine, but  that  they
           didn't have time to take it.
           In addition to changing the orientation of the individual  courses,  the
           proposers also intend to expand the network to an additional six hospitals.
           A total of 16 hospitals is planned for 1971, and 30 by  1973.  User  hos-
           pitals will be asked to begin to partially support the cost of  the  ter-
           minals in 1970-1971 and by 1973-1974 to assume the full funding  of  the
           service. Since the project narrative submitted earlier  this  year  does
           not reflect these changes, the site visitors asked the project  staff  to
           submit additional material spelling out these changes.

           III.  FUTURE STAFFING PLANS
           As mentioned earlier in the report, there have been a number  of  staffing
           changes since the inception of the project. Dr.  Ralph  Ingersoll  and
           Dr. Lloyd Evans served as co-project directors until September  1969  and
           October 1969 respectively. When Dr. Lloyd Evans left  to  become  Vice
           Provost for Curriculum Development for Ohio State University, Dr. William
           Pace became the project director. He subsequently  was  appointed  OSRMP
           Coordinator in February 1970. When he assumed that  position,  his  time
           on CAI was reduced to ten percent and the supervision of the  project  was
           managed by a group of individuals, including Dr. Gerald Gaston, Mr. James
           Griesen, and Dr. Ayres D'Costa. This arrangement has  not  been  conducive
           to coordinated leadership.






          OHIO STATE FM Site Visit          6                       RM 00022,


          During the site visit, the team learned of several  additional  changes.
          Dr. Gaston is leaving the project to establish an  Educational  Services
          and Research Division of the College of Dentistry. Dr.  Pace  will  trans-
          fer his part-time duties on the project to Dr. Gregory Trzebiatowski,
          Assistant Dean for Educational Development at the College of Medicine
          Dr. Tizebiatowski, Mr. Griesen, Mr. Nime and Dr. D'Costa  will  serve  n
          an advisory capacity to the project in computer services,  evaluation  and
          educational development.
          If the project receives funds for more-than a year beyond July  1,  1970,
          full-time project direction will come from Dr. Paul Ertel,  a  pediatri-
          cian and Chairman of Medical Records at the Children's Hospital,  who  has
          been with the project for about three months  as  cours@author.  Dr.  Ertel
          seems to be spearheading the change of direction to a  shorter,  patient-
          care directed type of program, which would be modified to individual
          institutions. Dr. Ertel sees CAI as  primarily  a  diagnostic-dependent,
          problem-type of information service, the effectiveness of which  can  be
          measured by changes in morbidity and mortality. The  site  visitors  were
          impressed with Dr. Ertel and are convinced that he would  provide  stronger
          leadership than the project has enjoyed in the past.
          Individuals to fill the associate supervisor for evaluation  and  education
          positions are available from graduate students completing their  work  in
          the College of Education. The candidate for  the  evaluation  specialist
          position is currently a fellow in medical education who has  some  famili-
          arity with the project.
          Mrs. Rich, a course-author, and Mr. Samuel Morrison and Mrs. Juliana Hushak,
          systems analysts, will continue with the project.  Mrs. Graves and Mrs. Hearn,
          technical and secretarial level personnel, can be retained if  the  project
          receives continued support.
          Uncertainty of funding beyond June 30, 1970, has led to  lowered  morale
          and considerable disintegration of staff.  While the Medical School
          would continue to develop its CAI programs, both project staff  and  user
          representatives emphasized the work that would be lost and  the  disillu-
          sionment that would occur in user hospitals if the RMP project  were  to
          fold.


          IV.  FUTURE EVALUATION PLANS
          Evaluation efforts have lagged due to the major emphasis  on  development
          of an effective computer network and on a system for  producing  software.
          Physicians from user hospitals expressed the feeling that  the  programs
          are worthwhile, but they have not begun to assess whether it makes a
          difference in patient care.  Pre- and post-testing of  other programs  has
          been rather limited, with small sample sizes and results showing no change.







                                                                          RM 00022
                                              7
            OHIO.STATE RNP Site Visit
            0                                 e of the system by course, by time of
            Staff is collecting data on the us
              by hospital and type of personnel.  Plans are also mentioned for
            day,                                                               CAI
            instituting an evaluation which would related performance within
            programs to patient care recorded in medical records, although it was
            not clear how this could be accomplished since students are not regis-
            tered on the computer by name.  Staff's willingness and interest in
            investigating medical record audit data was not matchedv however, by
            evidence of concrete planning along these lines.
            staff described extension of the work performance type evaluation men-
            tioned in the first supplement  and  the  CIPP  evaluation  model.  The  CIPP
            model developed in the College of Education at OSU includes evaluation
                                                                                'lable
            of content, input, process and product.  In the limited time avai
            for discussion of the CIPP model, it  was  not  clear  what  application  they
            intend to make in terms of product specification.
            Cost benefit analysis was suggested,  but  the  project  personnel  felt  they
            could not begin this kind of analysis until the third year.  The hope
            was expressed that this aspect would  be  included  if  funds  are  adequate.

            RECOMENDATIONS
            The site visit team has mixed feelings about recommending future support.
            On the one hand, much time, money and  ef  fort  have  gone  into  developing
            the  cooperative  arrangements,  rapport,  the  hardware  network,  software,
            trained personnel, etc. to  its  present  level.  In  addition,  there  is  a
            lot of back-up expertise available  to  the  project  at  OSU  in  conjunction
            with the pilot CAI curriculum in the medical school.  The system has
            reached a point where  more  rapid  expansion  of  the  instructional  program
            library can begin. Within the  next  three  years  they  should  be  able  to
            evaluate more adequately whether the availability and use of CAI in
            community hospitals has an important effect on the improvement of patient
            care.
            On the other hand, the  site  visitors  believe  there  must  be  considerable
            emphasis on better evaluation techniques if the questions about the
            effectiveness of the program are to be answered in an effective wa-Y.
            Since not all of the  hospitals  have  PAS-MAP  (which  could  be  adopted  to
            provide certain types of patient care evaluation data if they knew how),
            other types of data also  need  to  be  used.  The  site  visitors  asked  the
            project staff to forward to RMPS an updated statement of goals and staf-
            fing and future evaluation plans   , since there appear to have been a num-
            ber of important changes in these aspects of the project since the        renewal
            application was prepared.  In addition, the site visitors made the fol-
            lowing stipulations:
            (1) The emphasis on  the  project  should  move  from  the  technical  aspects
                 of the development of the CAI hardware and software to the develop-





                                             8                       RM 00022
          OHIO STATE EW Site Visit
                ment and application of instruction and evaluation,, Evaluation
                should include references to support from sources other than RMP
                and use of PAS-MAP statistics or other data to evaluate the effect
                of problem--oriented CAI on morbidity and mortality, etc.  ,
             (2), The project should not be expanded to additional hospitals until the
                above is well underway.  It did not seem practical to extend the
                network until a larger number of more patient-care directed programs
                are developed, since the physicians and nurses, etc. at the present
                user hospitals stated that present courses were not the most practi-
                cal.  In fact, proper evaluation techniques may prove more effective
                if fewer hospitals were used.  However, the site visitors would not
                recommend dropping any, for obvious public relations reasons.
             (3) There should be a full-time project director.  Dr. Ertel seems com-
                petent to handle this responsibility.
             (4) RMPS staff should provide close scrutiny of yearly progress reports,
                with a site visit if necessary, to insure that better patient care
                evaluation techniques are being developed and employed.  The  site
                visitors realize that it will probably take three more years to ade-
                quately evaluate the effectiveness of the CAI approach.  The potential
                appears to exist at OSU, but if RNP wants a satisfactory trial  of
                .CAI, adequate time should be allowed and the project monitored yearly
                to insure that the desired outcome is obtained.
             (5) RHP funds should not be used to purchase a computer in the second
                year.  Time-sharing arrangements should be possible with all of the,
                ,computer resources available to the project.
             While the site visitors reached a consensus that the project should be
             continued for an additional three years, they were not able to agree on
             the level of support.  Both site visitors agreed that the level of fund-
             ing probably could be substantially reduced without impairing the project
             as a pilot test of CAI.
             One site visitor felt that the project could be accomplished at a level
             of a maximum of $100,000 per year.  The other site visitor felt a level
             of approximately $192,000 for each year would be needed to adequately
             complete the pilot study on the assumption that additional  hospitals
             would not be added to the study.  An itemized budget for the $192,000
             recommended level follows:







          OHIO STATE RMP  Site  Visit      - 9                       RM 00022



          Personnel:
             Project Administrator                     $24,273
             Assoc. Admin. - Evaluation                18,064
             Assoc. Admin. - Author-Consultant         16,935
             Systems Analyst - 50%                      8,174
             Systems Programmer                        16,347
             Technical Editor  -  25%                   2,750
             Coder Specialist                           7,700
             Admin. Assistant                           8,003
             Typist                                     5,720
             System Monitor                             4,950               $112,916
          Consultants (subject matter experts,                                12,000
             course-authors, instructional
             materials   specialists)
          Supplies                                                             4,750
          Travel                                                               1,500
          Publications                                                         @,000


          Other:
             Line Charge -  10  lines                  37,200
             Fee for Disk  Storage  -10                 3,000
             Supply Allowance                           1,000
             Telecommunications                        17,230
             AV Accessories                             1,260
                                                                              59,690

          TOTAL                                                             $191,856





















                                                                         7/15/70

















    @@. @  0                                     0                                         0













                                         REGIOITAL lr-?DICAJ, PIZOGIL@IS SERVICE
                             s@iziaply OF AN OPERATIOIIAL SUPPLEZE-N"'L GPT@NT APPLICATION
                                              (A Privileged Coiiiniunicat:ion)



               OHIO VALLEY P,@"IONAL 14EDICAL PROGRA14                   RM 00048    7/70.1
               1718 Alexandria Drive                                     June   1970    Review    Committee
               P. 0. Box 4025
               Lexington, Kentucky  40504

               krop,, am Coor i@rator:  William H. McBeatli, M.D.

               Requested
               Prograni
               Period:              -Ist   Year    2nd    Year   3rd Year  -4tli      Year     t-.h Year     To ti 3.

               Direct Costs            $640,178       $645,583    $668,544        $232,101     $61,695   $2$248,101
               Indirect Costs           140,107        157,162     166,6@,,9        60,551      13,088       537,757


               TOTAL                   $780,285       $802s745   $835,393         $292,652     $74,783   $2,785,858


                           The   Region's    planning    grant war for ti..,o years,                 1967-
                           December   31,.1968.   During   the   first   year   a   total   (,f   $346,760
               was  rqadp-  available  and   $407,238   the   second.   In   Novcraber.-   1968,   following
               A   September   site   visit,   Council   considered   the   initial    operational    grant
               application and recoim.@tiended support of $866,000 (d.c.o.).  Fiscal restraints
               prohibited DL@dj'P funding at the recommended level'.  A total of $799,195 (d.c.o.)
               was provided  for  sl.lpport  of  Core  Staff  2ctiviti.es,  e,  Coryi@i@iviLy  I.Iospit.11
               Staff  Development   Project   (ij@2);   a   Library   Extension   Service   Project   (i[4);
               a   University   Continuing   Education   Resources    Project    (#5);    and    additional
               planning  for  a  Regional  Medical  T.V.  Project  (i'1,3);   and   a   Drug   Inforriiation
               Services   Pro4ect   (.96).   in   addition   a   Patient   Origin   Study   was   initiated
               under Core,, with $50,000 carried over from the 02, planning year.
               In February 1969, Council consiec@rcjthe Region's first operational'
               supplement application which consisted of four projects:  Autoniated Multi-
               phasic   Screening   (-@7);   Coronary   Care    Denionstration    (#S);    Radiotherapy
               Dosimetry (,19)- Re,,iorial Stroke 16'Aanaf.*c.,,aent (ii'10); and Rt@2C,al I'loiae Cire
               Demonstration  (iPlI.).  rilie  entire  application  vyns  deferred  for   a   14t-ircli
               1969 site visit.   In May 1969,, Coiincil a,-ain                        the
               application and recommended a total of @305,000 (d.c.o.) for the firc@t
               year support of the Ifultipliasic Scre(,@:iiiig Project (i'@7), the Stroke
               ment Project             and  the  Ilome  Care  Der@ionstratio;i  P).-ojcct           The
               Coronary Care Project             x@,7as disapproved iiil:h t:@ic- advice that-.  it  be





             OHIO VALLEY Regional I,.tedical Program      -2-              RM  00048   7/70.1

             disapproved i-ii tli  encouragement  that  it  be  revised  aiLid resubmitted     along
             the lines of the               recommended by the spc@cial.   radiation     therapy
             coii-L,,aitte(; which were endorsed at the llay Coui:icil meeting.  In  regard   to
             Project P(7 - Ifultipliasic Screening, the  Couticil,'s  a'@ppyoval  was  coLitigent
             upon submission of evidence  that  the  project,  as  c@iif@@,cAved,  could  be  accon-
             pli.slied within the limit of the  budget  recorpmendcd.'  "  In  December  1969,
             Council  reviewed  a  revised  proposal  for  project  #7@iand  found  it   acceptable.

             In  its  December  9,  1969  revieT-i  of  the  Re8ionts  non-competing  second-year
             operation  grant  application,  IU,113S  staff  believed  that  the  progress  of
             the individual operational components indicated that the Ohio VIlley
             Program  had  evolved  from  a  purely  planning  state  into  an  operational   one.
             Also, there was evidence of increased involvement in the program by
             medical  schools,  hospitals  and  CoLiaprehei-irive  Health  Planning  agencies
             throughout  the  Region.  The  Region   reported   that   it had officially
             established  as  its  number  one  priority,  the  development  and   more   effec-
             tive  utilization  of  health  manpower  for  the  delivery  of  improved   ambul.a-
             tory care. As a result of this  review,  the  Pcgion'xqzis  awarded  the  com@ii-.,.ted
             level  of  $749,195  (d.c.o.)  for  continued  support  of  Core  and  four   projects,
             in addition it was granted the use of @15,000 of carryover funds to
             ,initl,ate planning activities for Project #10        IteF@ional Sti7oke
             The request to use @136,605 of un@tpendc.@d 01 funds for partial restoration
             of  activities  was  deferred  pending  submission  of  additional  inf.ortyl-ation.
             In 16farch 1970, Staff reviewed the revised request to use $175,265 of
             adjusted tine,-,pended  01  funds.  The  review  resulted  in  $160,265  of  un-
             expended  funds  being  approved  for  use  in,  Core  and  projects  2,4,5,  and  6.

             The regiorl's second-year operational program is currently funded at
             $924,1@.60  (d.c.o.)  of  which  $175,Z65  is  from  01  carryover.  In   addition,
             two of  the  Regions"approved  but  unfunded  projects,  #7  Automated  Iii'ulti-
             phasic  Screening  ($200,000)  and  --Il  Rural  County  Home  Care   Demonstration
             ($90,000) are  to  be  funded  in  the  near  future  froii  the  recently  released
             $5 in!'Ilion  carried  forward  from  FY,'1969.  As  a  result,  the  total   amount
             of direct  cost  funds  available  to  the  Region  during  the  02  year  will  be
             $1,214,460.  (For  detailed  listing  of  projects  see  attached   "Review   and
             Funding History".)

             Present APPiLc- t@ioq
             The  Region  emphasizes  the  point  that  the  projects  of  this   application
             have a direct relationship to  the  current  thrust  of  OVPI-.!.P  which  is  "The
             development  and  irore  effective  utilization  of  health  manpower  for   the
             delivery of improved ambulatory care."  This program emphasis was selected
             by the PAC a,,,  the  primary  focus  in  an  effort  to  achieve  regional  impact,
             and to serve as  a  basis  for  restriction  and  selectivity  in  the  use  of  OVRIIP
             resources.  To  further  define  "Thrust"  for  policy  tirt!t  operational   purposes,
             the  RAC  selected  six  specific  areas  for   priority,   attention   pai:a-rledical'
             personnel,  emergency  services,  prevention  and  fol.lo@.?-Up,  coordiatioii   of
             community  resources,  patient  medical  records  and   @z.nctittitional   ambulatory
             care  programs.  Of  these  it  h,-ts  become  increasingly  apparent  that  two
             particular  areas  are  of  special  concern   throughout   the   Region;   paramedical
             personnel-).,            phy,-,.ici,il'i           and  improvement   ind   expansion
             of organized ambulatory care programs.





              01110 VALLEY Regional.14ecl-'I.cal Progrn-m     -3-                 RM   00048    7/70.1

                                                                                                         Requested
              Project V-12 -  o@ip
                                   ,I@MAssisted I'lladiotlie):apy Dc),siiiietry  I,)e!poLirtration     First Year
                               This proyc@i7@'S           0 also             Al             9,           $222,884
              during the Februarylclt.@P-,cvic@-i Cycle at i@;ilich tlric  Corr---Liittee  recommended
              approval   as   requested,   contingent   upon   Councifs   policy   regarding   fundinc,
              of dosimet@y.  Council recommended the         project  be   returned   to   the   Region
              with  encouragement  to  revise  and  resubmit   along   the   lines   of   the   guide-
              lines recoi-f.-nended  by  the  Special  Radiation  Therapy  CoiTii@,iittee,  which  were
              endorsed by the Council at this meeting.

              This   three-year   project   proposes   to   utilize   the   technical   competencies
              and  electronic   analysis   capability   of   the   University   of   Kentucky   Medical
              Center,  the   University   of   Louisville   School   of   Medicine,   the   University
              of  Cincinnati  College  of   Medicine,   and   the   professional   skills   of   local
              radiotherapists  in  fifteen   community   hospitals   to   improve   the   ease   and
              accuracy  of   radiation   therapy   dosirietry.   Initially   the   program   will   be
              available  to  the  medical  center  hospitals.   'During   the   latter   half   of   the
              first  year,  the  program  will  be  available  ---oaliraited   number   (at   least
              six)  of  corr,--,iunity  hospitals.  During  the  second  year,  service   will   be   made
              available   to   all   hospital   radiotherapists    employing    supervoltare    external
              beam  therapy  in  the  Pe,7,ion.  Also,  during  the  first  year,   a   program   of
              consultation  visits  to   community   hospitals   will   be   initiated,   a   program   to
              train  dosiriietry  assistants  will   be   initiated   in   each   university   center,
              and  a  program   steering   committee   will   be   established.   An   evaluation   plan
              is presented.


              Second Year: $258,405                              Third Year:      $277,704

                                                                                         Requested
              Project Yr'13 - Advanced                 Technolopist                  First    Year
                                                                                    -.$35,261
              by the University of Kentucky Medical Center, and five
              collaborati@,institutions; St. Joseph                    of    Lexington,    Central
              Baptist  Ilospital  of  Lexington,   Good   Samaritan   I-Iosptial   of   Lexington,
              Lexington  Clinic  and   Louisville   General   Ilospital.   Its   purpose   is   to
              investigate the possibility of improving the utilization of radio-
              logic  rianpoi-@r  through  the  development  of  a   program   to   train   properly
              motivated,   carefully   selected   Radiolooic   Technol.ogists   to   perform    many
              activities  currently   performed   by   a   Radiologist.   The   overall   plan   is
              designed  to  determine  which  and  how  niativ   of   the   Radiolo-ist's   present
              duties can be assumed adequately by                           trained     Radi.ologic
              Technologist  and  to  prove  that  selected   lladi.ol.ogic   Technologists,   cart   be
              trained   properly   to   discharge   these   duties.   In   addition,    information
              will.  be  obtained,  by  testing   techniques,   about   the   selection   of   Trainees,
              the curriculum and     Lez,@cliing   methods.   First   yeir   activities   include:

                                     Develop PEPT Ch;:ix-t
                                     Sympositti-a on Cirrictilu.,,-,i,  Teaching  and  Testing  methods
                                     Consultations with Padiolo,,ic Educators
                                     Fo;-iLtilate Te,,;ts for Appll.cotit,,i
                                     Develop CurrJ..ctilL,,-a





             OHIO VAI-,LEY  Regional Medical. Programs  -4-                       101 00048 7/70.1

             Project i'rl3 - First'year activities (cont.)

                                     Prepare 1-@l-aster IIcinual
                                     Detail Evaluation Proceedures
                                     Recruit  and  Test  First  Class  of  Students
                                     Begin Training of First Class of Students

             An advisory  group  cor,@posed  of  members  of  four  Radiology  Associations
             will meet at unspecified intervals to advise on various aspects of
             the program.

             The students' initial year of Training, 4.8 weelcq, will be tat@en in
             the Iledical Center  and  a  basic  outline  of  the  curriculum  is  presented.
             The second year,  on-the-job  training,  will  be  tal.@eii  in  collaborating
             hospitals.  Class  size  will  be  limited  to  six  trainees,  or  24  trainees
             in  four  years.  Specific  program  objectives  and  plans   for   evaluation
             are presented.

             A major itc-,ni in the budget catecory is for maintenance income allowances
                                                C)
             for trainees, @500 a  month  per  trainee  for  the  first  year  and  $200  a
             month for year two.

             No plan is presented  as  to  how  the  project  will  be  supported  after  the
             fourth year, when PJI.P support would be terminated.


             SecotiiYear:  $99,61.4     Third Year:  $109,798  Fourth Year:       $113,284

                                                                                  Requested
             Project ir'14 -  r@Lo ic Assistant - This project is a               First   Year
                             cooperative effort between the Cincinnati             $37,966
             Technical Institute, the University of Cincinnati Colle-e
             of Medicine, the Cincinnati General Hospital and the Christ
             Hospital.  It is designed to develop a tx,7o-year  associate'degree
            ,program  for  instruction  of  Urologic  Assistants  which  would  prepare   them
             to perform selected activities which are currently the sole responsibility
             of Urologists. It will  serve  as  a  model.  that  can  be  used  in  developing
             guidelines for a National Ui.-ologicil Assistant Training Program sanctioned
             by the American Medical Association and the American Urological Association.

             The program will ccnsist,of 5 ten-,,jeek quarters of classroom instruction
             at Cincinnati Tecli@,iic,.al Institute end 5 tei-.i-weel-, quarters of on-the-job
             training at one of the two collaborate  hospitals.  The hospital training
             will itself be subdivided into course work and practical experience.  Two
             groups of students will alternate simzil.tc,,nP-oi)sl@@r between the school. and the
             training sessions. The first clas,.,x-ihich will  ini.t:!.,ite  its  studies  in
             Septe,,aber 1970,,v7ill consist of 10 iCo 14           aiiJ  successive   classes
             .will gradually be increased to meet local and                clc,-iiatids.
             Progrita content will be             to eq,,j.'L.p the strident to perform duties,
             which include dl.@ifnostic studies, assiE@t@'tuce in                          and@



               01,IIO VALLEY Region!], medical Prog3:@,@ii!                   @,i ooo@,.s  7/70.1

               related care,  'Vac@c duties might        in the.
                                                                         purs-.1@@  @
               ambulatory clinic, private pliysici.art'r. office or                       Prerequisites
               have  been  cstablishud  for  students;  and  recruitment  xiill  be  done   by   repre-
               sentatives of the Cincinnati Technical.                  who visit area high
               schools  annually.  Special   interest   is   expressed   in   recruiting   ex-failitary
               corpsre,en,
               Specific objectives and a plan for their C"7,11,-Liation is p     resented.      Upon
               termination of PIIP support the progr.-iin will be subsidized by the Ohio
               @rd of Reg&nts.

               Second Year:      $33,900                             Third Yea)::     $33,900
                                                                                         Req@sted
               Project It-15      ii@-ni Associate                                       First   Year--
                              'Ciiie@ five-year 'pilot training project is                  $102,708
               sponsored by the University of Kentucky Medical School           and is
               supported by fotir'particl.  pating institutions:  Kentucky lieOical
               Association,  Kentucky   Academy   of   General   Practice,   Kentucky   Academy   of
               Pediatrics  and  the  University  of   Kentucky   College   of   Education.   Its   pur-
               pose  is  to  develop  a  txio-year  training  program  to  prepare  a  new  type  of
               @health  worker  called  a  Clinical  Associate  to   assist   the   practicing   physi-
               cian  in  a  greatly  expanded  clinical  role.  The   first   year   of   the   project
               will be devoted to  developing  the  curr'Lctiluiii,  selecting  and  testii-ic,  the
               trainees, and acquiring the faculty.
               The  second  year  will  begiii  the  training.  The  f-.i.rst-yeir  course  is  a  con-
               centrated  study-practice  course  to   prepare   the   Generalist   in   the   sense
               that  the  Clinical  Associate  will  be  trained   to   perform   those   activities
               which are general  to  clinical  practice  of  any  physic-,ian(li-.i.sto7.-y,  physical
               ex,q,r,is, diagnostic lab.procedures, etc.), This training             be taken in the
               Medical Center.  The s6cond-year course I.F, a closely supervised preceptor-
               ship  during  which  -the  Clinical  Associate  will  sharpen   his   skills   and   in-
               crease  his  coriipetance  under  the  tutorage  of  a   carefully   chosen   practicing
               physician. At  this  til-iie  lie  Nqill.  elect  to  specialize  either  as  generalist
               or  as  an  associate  to  one  of  the   medical   or   surgical   specialists.   Class
               size will be limited to four trainees for the first class which will be
               initiated  in  the  second  project   year.   Six   additional   students   will   be
               accepted,  the  third  project  year  and  ten  students   will   be   accepted   the
               fourth project year,       The  fifth,  project  year  will  be  for  coriipleting   the
               training of the last ten students and                  out   the   project   study.   If
               feasibility is demonstrated, an ongoing Clinical Associate Training Program
               will be  pliased  in  as  a  permanent  progrfit@ii  of  the  medical  Center.  Being
               considered is,the granting of an Associate Degrc:e, professional certific@ition
               of the academic program, and a Clinical
               with in the Medical. Association.
               Specific objectives  and a plan for
               Second Ye I::                                                           $1,32,282
                o i i, t @y      $118v8l7                                                $61,695





               OHIO VALLEY Regional l,ledical Programs   -6-                             'rd4    00048    7/70.1


               Project '9'1"16 - Lase-r- Treatment of Cancer                                              Requested
                                                        project      OPOSC3 tile                          First Year
               tion of the laser                  and e...pc-x.-tisc- at the Ufiivc@rsi@@ly of
               Cincinnati   Medical   Center,   to   locate   patients    from    tbi--c)ttghoLtt    the
               Region.  with various forms of mali@Li@.).Licy                  cannot   be   treated   by   coii-
               ventional    types    of    cancer    therapy.    Through    the    prograni.it    is    anticipated
               the number of patients  who will be treated by laser annually  will increase
               nearly  tcnfolde         Referrals   will   be   r,@iade   by   attending   physicians   to    their
               respective             boards.     The  li.,,er  treatment  for   tile   patient   I.;ill   be
               approved   by   the   Laser   Faculty   Advisory   Board   of   the   I,,fedical    Center.    The
               treatment cycle, after referral,              would   be   ambulatory    or    inpatient    as
               indicated.      Arran,,ement:@, for adequate follo,.7-up will be                   by   the    Liser
               Laboratory   with   the    referrin,,    physician,    in    cooperation    with    the    local
               community hospital Tunio.r Boards or other cancer facilities.                      Special tests
               will   be   performed   with   lasers   to   diagnose   pre-itivasioti   cancer    of    the    cer-
               vix and breast tumors.   In addition to providing patient                    care      services,,
               the Laser Laboratory will provide educational ictivities                     for    health    pro-
               fessionpls in the Region.

               Specific objectives and an evaluation plan is presented.                       'Itte  first   year
               budget consists of $40,000 for personnel. and $10,000 for patient nioiLi.toring
               and calibration equipment.


               Second Year: $40,000                                    Third Year:        $40,000

                                                                                                          Requested
               Project ',@17 - Pediatric Cardiac Clinics                                              First Year
                                         ti@l."(-@e--year-proj-ec-t-i-s designed to expand             $4.9,175
               and extend the scope of pediatric heart clinics conducted,,
               throughout   Southern    Ohio,    by    the    Utiiverrity    of    Cincinnati    College
               of Medicine.       The   present    clinic    system,    which    offers    basically    diaglic)sic
               and   referral   services,   serves   Cincinnati    and    six    counties.    It    will    be,
               extended by openitic, three additional clinics in the counties now
               being   served,   and   expanded   by   openino-   clinics   in    six    counties    n6t
               presently   being served.   The frequency of the clinic sessions in the parti-
               cular   localities   is   not   finalized,   bo@47evei.,    indications    are    that    two-
               three   clinics   per   year   will   be.i.,equir(@d,   except   in   one    county    where
               bi-n@ionthly clinics seem indicated.             The school -ci.-eetilng program for
               detection of heart disease which                  recently    introduced    in    two     counties
               will   be   expanded   throughout   the   area,   title   priority    Eit:tcntion    to    those
                                             0
               schools   havin-   un,.tstially   high   enrollment   of   low   I.Licorie   and   lptnority
               groups,   Plans   for   an   educational   aspect   are   to   arrange    county    t,@ic-clical
               societies'   meeting   to   coincide   with   tile   date   cliLiico   arc,-,   scheduled   in   the
               respective counties,          Attended    by    physicians    and    public    health    nurses,
               third, would allow fo@:t,.ial discussion of pL-@.-,iiitri-.c                    problems  ,IL-.td
               afford            opportunity  for  case   confcrcnce,7,,   on   rc.!fc.@ri.-ccl   patients. t.@n
               evaluation plan is presented.


               Second Year:       $39,700                                    Till,):,(!           4 1. , 0 1 0






                                                                            MA  0001@8  7/7C).1
             OlilO VAI,LEY Regiotial 1,1@cliczll Prograins    ..7-


             Project i@"18                                                               Requested
                             This project is a cooperative effort       by the         .'.First Year
             University of   Kp-ncitcl@y II(--dJ.ccil Cc,@-iter, its sponsor, end the.
             Clover For]., O@tt-Pa-L-,'-ept II-"clical Clinic N@7hicii serves the indigent
             of rural tppaic@Ichia,  Its purpose is to devel.op nothot@s to help alleviate
             the irianpoior  ch'o@"cage in the care of                    -s and to deteri-,i-ne
             the most cost-c@j'fecti.v(:-: method of col.Icctl,ii,- ppt-L@er,@t medical history
             inforr@-,--atioLi, x@7!iilc at the ser@-te Li.t.-te,     the                 quility,
             and physician and pciticnt acceptability.  Durin" tiae first ha        ,f  of  the
             project year comparisons  wil.1  be  raade  of  tire.  effectiveness  of  various
             history-takin- tcchriici-(.ic@s  applied  to  randomly  selected  patient  groups
             at the General I,.Icdical. Clinic at the University and  gt  the  Cl.ovc,.r  Forlt
             Center.   Using the Tc-clirtiqi,icc-, found    cost-effective dui-,@'@.iig the initial
             six-month period these applications xyill. be expanded into first the
             family practice cl.i.nic, then the  other  r@iedical  r@pecl.@ilty  clinics,  and
             finally into ill. outpatient clinics nt the University of Kentucky
             Medical    Center.  In the 03 project year the progra-ir,.riicd  history-takiii-,
             technique found to be rr,,)st applicable  Will  be  e),terye@ed  into  the  office
             of a private practitioner of internal medicine and into a group practice
             clinic.  Utilizing  the  data  base  and  experience  accur@-tilated  during   the
             first tiio years, it is also planned to dev,cl.op diagnostic decision stip-
             port by computer during the 03 year.  A plan of evaluation is presented.
             The 01 year budget reflects large amounts for computer time, $10,000
             and equipment rental, @59,534.


             Sc-conc,'. )lc!,-irt $62,940                      Third Y ai7:           50





                  OIIIO VALLEY Regi.onzl l@Ic.,(.kical Progrz:tra                                      11M     00048      7/70.1


                                                      Rr,,Vlrj,,'17 AL@TI)           IIIS'f,ol"y


                  lst Year Planning Award
                    (IIoveinber  1966 Council)                          I/l/67      -      12/31/67@             $346,760
                  2nd     Year     /award                               1/l/68      -       12/31/68
                                                                                                                  346,791

                  2nd Year Planning Aiqirci t@riieiidcd
                         (February  1963 Council)                       1/l/63      -       12/31168              407,238

                  IIIITIAL
                          (Site     Visited      Septc,,-.iber      1968)
                             (I,,Tove,riiiier    1968    Council.)

                                                                                                   FUIrIl.,"It@"D  (d.c.o.)
                                   PRO,T-LIC,TS                  PROJECT                      01   @ye,7ir             02      'Zenr

                       -  Core Staff Activities                         3      years              $376,761                 $397,393.*
                  #2     -Coti-i@,,ii-,,nity llospitil Staff
                          Developiient                                  3      years               230,690             265,970
                  #3     -Regional Medical T. V.                        I      years            20,020                       -0-
                  #41-    Library        Extension         Service      3      years            75,954                   90,459*
                  #5     -University       CoL@.tinuing        Ed.
                          Resources                                     3      years            91,270                 141,440,,,
                  #6     -Drug Inforp%ation Service                         Additional               4,500               14,200.,@
                                                                            Planning

                  FIRST OP).,',"IATIO!qAL SUPPI,El@,'PI;,T APPLICA'rlO'--l
                          (February 1969 Council)
                          (Site     Visited     I-larch      1969)
                          (11@iy 1969 Council)
                                                                                                                               FUTURE
                                                                                 FIT@IDTD (d. c. o.                      SUPPORT
                                        PIZO@CTS                                   01. Year                02 Year               03 Year
                  #7   - Autor@i@il.-ed l@ul   t3-plia@;ic Sci:eeLiing           $200,000  (1)                  $200,000            -0-
                  #8   - Cornoary Care Dc-iToi7istratioLi                             Disapproval      iiith     ad,@,-ice     to resubmit
                  #9   - Radiotherapy Dosi.r-etry                                     Disapproval      with         advice     to   resubmit
                  #10- Regional Stroke 14,@,.tiaL@,erient                            15,000       **              15,000           15,000
                  fill-    Rural.    I-lome    Care     DeTi,,on-stration            90:000 (1)                  127,654         127@65t'@

                  REVISION     OF     g@7                      ScrceninR
                              (Decernber      3.969       Council)
                  Original     approval     @.7,as     contingent     upon     subniiisioi-i      of evidence that the project,
                  as conceived,  colil.d be accomplished within the liti,.jt: of the budget recomtnend@l.,
                  Council  found the revised proposal acceptel)lci.

                     Partially funded                   01 c,,rryover
                     Totally                         01,





                01110 VAI,Ll@@'Y             l@icdical. Prog)::Ctra     -9-           Ri@l OC@048 7/70.1


                SECOND OPEjl,,ATIO,'.-T,Al,
                        ,11(7


                Proj ect
                #3 - (Renci@,al) Regio,-i@,,l Ilicdical T. V.                         Disar@proved v,7itli adxrlce


                        OP'-I@.,R4TIOIIAL SUPPLYI-ff@NT APPLICATION
                          Ynly@ 1970 Council.)

                -#12  - Co       e): Assistcid Radiothe                          Domoiistraion
                #13   - 7,'dvanced Rediolo)-,!.c Tecl-ino
                #14   - -U'r o-1 o a-i c- A-s" "s'l-s t-a'@'n' t-
                #15   -
                #16   -
                @A 1 7-
                   18 -                     ical I.Iis t@




























                                                                                                   RMPS/C-.RB/5/21/70





                                                       A Privileged Communication


                               SUMMARY OF REVIEW AND CONCLUSION OF
                                    JUNE 1970 REVIEW COMMITTEE


                               OHIO VALLEY REGIONAL MEDICAL PROGRAM
                                           RYi 00048  7/70.1

                         FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


             Gen6ral4  The  Committee noted that this  application  requests  funding
                       for a  variety of new operational activities in the Ohio
                       Valley Region. Four activities related  to  training  and  the
             Comm:[_ttee's approval was based on the Ad Hoc Continuing Education  and
             Training Panel's assessment of their technical feasibility; one project
             was a revision of a Dosimetry proposal returned for  revision  in  line
             with Council guidelines on Dosimetry and while the  Committee  felt  it
             was well-planned, they requested additional review by a  member  of  the
             66uncil' Ad Hoc Committee which developed  the  guidelines.  Two  pro-
             jects were returned for revision and one  was  disapproved.  The  overall
             application was approved with specific conditions.
             Project #12 - Computer Assisted  Radiotherapy  Dbsimetry  Demonstration

                       'The Committee considered this project acceptable  and  'worthy
                        of support, noting it is an important  first  step  toward
                        providing regional tddiotherapi8ts  with  reliable  radiation
             therapy dosimetry. However it  was  felt  that  additional  technical
             review was needed by a member of the original Ad  Hoc  Committee  which
             developed the guidelines on dosimetry for  Couricil's  considetAti6n.

             Re-commendation:  Approval I - but recommended for technical review
                              prior to Council.
             .Years:  01 - $222,884       02 - $258,405        03    $277,704

             Project #13 - Advanced Radiblogic Technologist

             Critique:  Committee concurred with the Continuing Education and
                        Training Panel's view that  this  project  is  technically
                        feasible and adequately planned.  The educational needs bav6
             been identified with data to indicate the acute shortage of radiologists
                 the lack,of likelihood that this  shortage  will  be.ameliorated.
             The objectives ate stated in clear and measurable terms  and  are  likely
             to a ieve the Region's mission if  attained.  The  application  does  not
             contain the details of prograin,de8ign., but rather methodology  where-
             by such design will. be determined. The time frame  of  the  activities





             OHIO VALL-EY'Regional Medical Program     -2-         RM  00048   7/70.1

             seems reasonable and is well defined. The  project  probably  can  be
             carried out with the budget, personnel and  plan  proposed,  although
             it is experient.  The educational resources in the Region are in-
             volved.  Evaluation should provid@-i6-1,i.4b,le and valid data, and
             adequate staffing has been provided; but it is  implied  the  program
             may become a part of a baccalaureate program and it would be
             assumed that the tuition funding mechanism would then apply.
             It was noted that this.project has been approved by the Manpower
             Utilization Branch, Nation Center for Health  Services  and  Research
             Development and that as of june 18, 1970, the Chief  of  that  Branch
             was optimistic as to the possibility of its being funded.
             Recommendation:  Approval I - to be funded only if not funded by@
                              another agency.
                                I
             Years:  01   $85,261        02 - $99,614       03 - $109,798        04   $113 284

             Project #14 - Urologic Assistant.
                         The Committee generally concurred with the observation of
                        ,@the Continuing Education and Training Panel regarding  this
                         project.  The need is well-stated and documented.  Objectives
             are stated in the general terms of activities in a  time  frame,  rather
             than behaviors of the learners.  The project appears feasible within
             proposed time frame, budgeti and personnel.  Educational resources are
             well described and involved in the project.  Little attention is givdn,
             to-evaluation of the impact on patient &are in quantity and quality
             dimensions., The budget is modest. This  type  of  manpower  specialist,
             to provide assistance to the physician, is so  highly  specialized  that
             it Would set a precedent for the establishment of numerous other training
             programs which might not have a direct bearing and impact on KD? activities.
                     Note-  Since Committee reviewed this project, it has been funded
                            by the Division of Allied Health.
             Recommendation:  Approval  II - no additional funds recommended.

             Project #15 - Clinical Associate
                         Committee concurred with the observations of the Continuing
                         Education and Training Panel. The need for  the  project  is
                         described in generally accepted terms.  There has been a
             survey of physicians in the Re@ion and it would appear that they agree
             to the need for such a program and that a  significant  number  would
             employ such assistants.  The objectives ate stated in measurable terms.
             The educational resources of the Region are involved.  There are multiple
             -ro6i on evaluation@including re-examination of the criteria for acceptance




                                    'bdical Program                    RM  00048  7/70.
             OHIO VALLEY Regional 14                      -3-


             of students, the adherence  to  objectives  concerning  task  accomplishment,
             evaluation of actual performance  of  the  trainees  and  determination
             of the physician sharing of  the  trainees.  It  was  questioned  whether
             95% effort of a research consul,-@,@l-n.t will be enough to carry out the
             evaluation procedures. It was note  -that,.the  small  number  of  trainees
             and the expected distribution of  these  trainees  to  various  medical
             groups such as practitioners,internists, pediatricians, surgical
             specialists, etc., may make the  problem  of  evaluation  of  the  effective-
             nesg of these men within each  speciality  difficult.  The  Conmi-ittee
             suggested that an attempt be made to  increase  the  number  of  trainees
             to provide a sounder evaluation  of  the  effectiveness  within  each  area
             of service. The increase in trainees  would  also  serve  to  reduce  the
             expense per student trained,  which  was  considered  very  high.  Although
             no specific plan is presented for phasing out,  it  is  indicated  that  if
             successful, the program would become a  part  of  the  regular  curriculum
             of the Tlniversity And be funded in  the  usual  fashion.  Committee  concluded
             the project is technically sound and capably  directed.,  And  Alth6bghit  is
             of high risk and great cost, it should be endorsed to test the hypothesis
             implicit in this experiment

             Re ompiendation:  Approval I
             Years:  01 - $102,708  02     $111,024   03 - $132,282    04  -  $118,817   05  $61,61

             Prolect #16 - Laser Treatment of Canter

               iti ue, The Committee considered the   proposal too  narrow  in  scope,
                        involving primarily fellowship  training  and  little  else.
                        The support requested  for  fellowship  training  and  development
             is an aspet-t for which Committee requests  Council  policy.  In  addition,
             it was noted that there is no  educational  thrust  provided  for  practicing
             physicians Also, there is  no  clear  indication  the  project  would  directly
             effect an increase in the  number  of  patients  treated.  The  roblem  of
                                                                           p
             referral to this specialized center is not clearly spelled out, and there
             is no information on the,pr6motional  techniques  to  be  used  to  encourage
             this ref etrdl. The portion of the  project  concerned  with  colpbscopy  and
             use of laser needs strengthening and amplification.

             Recommendation:  Non-approval II - return for revision,

             Project #17 - Pediatric CardLo       Cl--'Lnic@
             Critique:  Committed agreed witht@ Ad Hoc     Cardiovascular  Panel's  comments
                         regarding this project.  It was   noted the proposal  is  justified
                         on the basis that OVMIP emphasis  is  on  improved  ambulatory
             care services; but that the need for expansion  of  clinics  is  not  clearly
             shown. The geographic areas where  the  clinics  are  to  be  maintained  are
             n t specified as to exact  locale:  hospitals,  health  de  artments,  etc.,?
                                                                        p
             The need for the @hoiioc.drdi.oscaii is not justified; it would  appear  that
             the trained cardiologist who will  e  in  attendance  at  the  clinic  should





             OIIIO VALLEY  Regional lledical Program        -4-            RM 00048 7/70.1


             eliminate the necessity for this   piece of  screening equipment
             V,611.trained specialists are more effective in determining whether
             a murmer is functional. or organic.  Although objectives are
             enumerated and a means of  attainment  outlined,  they  are  not  presented
             in quantitative terms thereby making it difficult to assess the
             ad6quacy of resources and  to  evaluate  the  budget  request.  The
             evaluation described is  an  appropriate  record-ke(2ping  and  accounting
             of the expansion and utilization of  services,  but  does  not  take  into
             consideration all the possible factors,and trends.

             Re-comniendatioii:  Non-@qpproval II return for revision.

             'Project #18 -          d @tedical IL-L,
                             Prograpiin(,,

              riti@e.  The  Committee  felt  that  initiation  of  this  project  should
                        await results from the large number of studies relative
                        to this type of activity being carried on -in various
             positions of the county.  The reviewers were not certain that programmed
             medical history utilizing computers is, in fact, time saving and valuable
             a indicated in  this  application)  particularly  with  reference  to  its
             extension to the community after the preliminary work has been accomplished
             at th  medicall@center.  The reviewers found the use of the computer in
             diagnostic decision assist an interesting part of the proposal.

             Recoiqmendation:  Non-appkoval I    no  RXPS  funding  recommended.


                                     SLZMRY OF RECO@24FNDATIONS


                    Recommendation     01 Year     02 Year     03 Year     04 Year    05 Year  Total

  1-2-@C uter       Approval I         $222,884    $258;405    $277,704      -0-       -0-     $758,99
  @ss               Recommended
  @ad               for technical
  ;Lpv       try    review prior
              n     to Council
  '-3    nc  d      Approval I -  To      85,261     99,614     109,798    $113,284    -0-      407,95
                    be supported
                    only if not
                    funded by the
                    Manpbw6r Utili-
                    zati.on Branch  of
                    NCHSRD

                    Approval II            -0-       -0-         -0-         -0-       -0
                    (no additional
                     funds recommended




            OHIO VALLEY  Regional  Yic@dical  Program      -5-             RM 00048 7/70.1





                   Recommendation     01 Year    02 Year    03 Year    04 Year    05 Year    Total
  -5               Approval 1         $102,708  $111,024  $132,282  $118,817      $ 61-,695  $526,526

  L6               Non-Approval          -0-        -0-         -0-        -0-        -0-       -0-
                   !I  -  (return
                   for revision)
  L                Non-Approval                     -0-         -0-                   -0        -0-
                   II  -  (return
                       r vison)
                   for  e   i

                                                                                                -0
                   Non-Apprbval  I        -0-       -0-         -0-        -0         -0
    aicai    Hisf0ty
  rOT  @APPLICATION    Approval       $410.%8@3  $469,043  $51@9,78     $232,101      I.,69            6
                       with
                       S   ecific
                        p
                       Conditions

                   (see individual projects)















                                                                                DRM1"/GRB'
                                                                                  7/15/70
















             0                                                              0                                                              0










                                REGIONAL MEDICAL PROGRAMS SERVICE
                     S      Y OF MI OPERATIONAL SUPPLEMENTAL GRANT APPLICATION
                                     (A Privileged Communication)


               OREGON REGIONAL MEDICAL PROGRAII,            RM 00012  7/70.1
               University of Oregon Medical School          June 19 70 Review  Committee
               3181 S. W. Sam Jackson Park Road
               Portland, Oregon  97201
               PROGRAM COORDINATOR: Edward M. Goldblatt,  M.  D.

                   sted

                  ram
               Period             Ist Year      2nd Y ar       3rd Year      Total
               Direct Costs:      $59,375       $?8,829        $14,843         $103,047
               Indirect Costs:    To be submitted

               Total              $59,375       $28,829        $14,843         $103$047
               HISTORY: The Regionis first planning  grant  application  was  submitted
                        in May 1966, returned for  revision  by  Review  Committee.  and
               resubmitted in August of that same year.  This  second  application  was
               approved and the 01 planning award,($166,494 d.c.o.) was  made  for  the
               period April 1, 1967 through March 31, 1968.
               Following a most encouraging site  visit  in  February  1968,  OM  became
               operational on April 1, 1968, with an award of $171,910 (d.c.o.).  This
               amount combined 02 planning funds with new funds for the support of one
               operational project.  A supplemental award was made on July 1, 1968
               ($343,045 d.c.o.) for six new projects, #2 Aq,@  #7.  Another  supplement
               for projects #8  -  #12 was approved but unfunded in February  1969.
               The Region was issued an 02 continuation award ($686,028 d.c.o.) effec-
               tive Aprill, 1969, with support for core and  seven  projects.  At  this
               time, there was also a site visit made to  examine  the  accomplishments
               of the first year of operations and to make recommendations  on  two  new
               projects to be acted on by the May  1969 Council.  The visitors reported
               significant progress and recommended the projects be approved.
               On July 1, 1969, an amended award ($854,146 d.c.o.) was issued granting
               the use of carryover funds for one-year support of  projects  #9  -  #12
               (approved - unfunded) and the two projects, #13 and #14, approved by the
               May Council.
               The 03 continuation award ($764,381 d.c.o.)  for  the  period  beginning
               April 1, 1970 included support for twelve on-going projects and one










               OREGON'                              -2-                 RM  00012  7/70.1
               Regional Medical Program

               new project, #15, which had  just  been  approved  by  the  March  1970
               Council.


               A listing of all  current  projects  follows  the  description  of  the
               present application.

               PRESENT APPLICATION:  This  is  a  request  for  an  additional  year's
                                       support for  a  project  formerly  approved  for
               one year only, plus a request for three y(a-ars'  support  for  one  new
               project.

               Project #12 R - Southern Oregon Diabetic Instruction and                Requested
                                Evaluation @roj@c .  This project had received         First Year
               one-year approval for t@;e period April 1, 1969, through March           $14,872
               31, 1970, but was iot @L@,,nded until July  1969.   In order to
               a]-'-,),,; f(-,.c a fall yea-,7 activists, and to fit into the present
                  i      -I p , O@,@   'seed and i-t-2ceived  a  four-month  extension
               -for the Deriod April 1, 1970, through July 31, 1970.

               The purpose of this  program  has  been  to  make  available  a  course
               of instruction for diabetic patients which will help them to
               understand their disease  and  to  regulate  their  diets  and  medica-
               tions. The ultimate  goal  of  the  course  is  to  effect  a  signifi-
               cant reduction in morbidity.    In  addition  to  the  basic   program,
               there are activities concerning education of student nurses,
               registered nurses, public health nurses, student and licensed
               practical  nurses,  dietitians,  institution  cooks   and   physicians.

               Although in  operation  for  only  nine  months,  the  Region  contends
               that the project has Trade excellent progress and seems to be
               extremely well received by  the  community,  a  factor  that  has  been
               noted by several national legislators from Oregon.  l@ile the
               original grant  expected  00  patients  to  attend  the  course  during
               the first year, the presently  projected  230  patients  and  80  family
               members seems a  more  realistic  and  attainable  estimate.  Also,  there
               had to be a reduction in the number of students based on the
               experience gained after the first course  when  it  was  found  that  a
               great deal of individual counselin- was necessary.      The Region
               believes that this project  is  unique  among  ORNP  projects  in  that
               it affects the lives of  citizens  directly  in  addition  to  improving
               the abilities and resource@  of  the  professionals  who  render  health
               care.


               The original one-year authorization was based on    Ithe  premise  that
               diabetic  patient  instruction  schools  are  capable  of  self-support
               and that ORNP support was intended as seed money for the first
               year. OIUIP believes that the time  needed  for  this  program  to  become
               self-sufficient was  underestimated  and  is  therefore  requesting  an
               additional year to be prorated on  an  eight-month  basis  due  to  the
               four-month extension mentioned earlier.








                OREGON                           -3-               RM 00012 7/70.1
                Regional Medical Program


                Project #16 - A TraininR Program for Personnel of Oregon        Requested
                              Health Care Institutions.  This program is        First Year
                designed to improve care of patients in health care institu-    $44,503
                tions in the Oregon region by providing informational courses
                aimed primarily at the entire spectrum of subprofessional health
                care workers.  The courses will be designed so that the students
                may comprehend and carry out their own specific resvonsibilitipq
                under existing formal institutional standards  concerned with the
                control of significant patient care problems.

                Participating institutions will select a minimum of two trainees
                to attend courses in hospital care problem areas. Trainees will be
                selected on a multi-disciplinary basis and efforts will be made to
                include a participant from a supervisory level of the institution.
                Courses will be presented in specified areas of the state to
                permit maximum participation by the smaller and more remote institu-
                tions.  Course content has been developed for the first year of
                presentation.  An advisory committee will plan future courses based
                on needs and requests of participants.  Evaluation of pre- and
                post-course achievement in skill, knowledge and performance will
                be accomplished by written tests and interviews.

                The project requests that funds collected through tuition be used
                to defray total cost of the program.  The sponsoring organization, the
                Oregon Association of Hospitals, has outlined a plan whereby member
                hospitals of the Association will contribute one-third of the cost
                in the second year, two-thirds in the third year, and will continue
                the program at the end of the grant period utilizing the association's
                own  resources.


                The Region believes that this proposal represents an approach unique
                in scope and without precedence among its activities in that it
                provides a multidisciplinary educational program directed towards
                actual worker implementation of modern hospital technology.  The
                outlined program will constitute a major effort by hospitals to solve
                their own basic patient care problems.

                Second Year:  $28,829                      Third Year:  $14,843





                                                -4-                    RM 00012 7/70.1
           OREGON
           Regional Medical Program
                                        OPERATIONAL PROJECTS
                                          (Direct Cost Only)

                                                                  INCLUDED
           PROJECT                                 CURRENT       UNEXPENDED        DATE OF
           AND TITLE                               BUDGET           FUNDS        ACTIVATION

                 Core                              $209,417         -0-

           #1    Heart,  Cancer,  Stroke   Circuit
                 Postgraduate Course for the
                 Oregon Region                     $174,204         -0-            4/l/68

           #2- Early  Diagnosis  and  Therapy
                 of  Cerebrovascular   Disease     $  27,825        -0-            7/l/68

           #4    Diagnosis  and  Treatment  of
                Cerebrovascular  Disease   and
                the  Influence  of  a  Stroke
                Clinic on Stroke Care:
                Str4D!:@@ Pro;lcct-- III           $  56,859        -0-            7/l/68

           #5    A  Stroke  Continuing   Education
                 Program  Planned  by   Community
                 Physicians:  An   Evaluation   of
                 Effectiveness Stroke
                 P-rnject IV                       $  31,567        $3,946         7/l/68

           #6 - Mid-Willamette Valley   Coronary
                 Care Training Program             $  52,164        -0-            7/l/68

           #7   -Training  of   Professional
                 Nurses  for  Coronary  Care       $,73,848         -0-            7/l/68

           #9   -Cen tral  Oregon  Heart,  Cancer
                 and  Stroke  Pilot  Program       $  24,233        -0-            7/l/69
           #10  -Coronary Care Teaching Aids       $   5,572        -0-            7/l/69

           #11  -Guiding Adult Patients with
                 Aphasia                           $  27,019        -0-            7/l/69

           #12  -Southern  Oregon  Diabetic  In-
                 struction  and   Evaluation
                 Project                           $   7,219        $7,219         7/l/69

           #13  -Mobile  Emergency   Cardiac
                 Project - Phase I                 $   6,249        $6,249         7/l/69

           #14 - Training  Programs  to  Promote
                 Better Care of the Diabetic
                 Patient                           $  39,306        $32,306        7/l/69











           OREGON                                 -5-              Rkl 00012 7/70.1
           Regional Medical Program



           #15 - Physician In-Residence Course
                 in Technique of Cardiology          $28,920         $28,920*    4/l/70
                                                    $764,381         $78,640




           *Negotiations are now under way to fund this project with new supplemental
           money made available by the release of five million dollars to DRW
           by the Bureau of the Budget.





                                                             A PRIVI)IEGED COL%fllt)NICATION



                                  SU@4liRY OF REVIE14 AND CONCLU')ION OF
                                      JUII@E 1970 REVIEW COI,;14ICTEE


                                    OREGON REGIONAL MEDICAI, PROCT@.AM
                                             P,M 00012 7/70.1

                            FOR CONSIDEI@,ATTLON BY JnY 1970 ADVISORY COUNCIL


              Project #12 R - Southern OreRon Diabetic Instruction and Evaluation
                              P@eSt.
              rii--ioue..:  The reviewers were favorably impressed with the progress made
                         by this program in reaching out into the rural  areas  of  the
              state to deliver this most needed L-ervice to diabetic patients.  T ey
              also noted the support for the project oil the part of both the  profl-s-
              si.6nal and consumer communities and the valuable  nursing  educational
              component.  The Committee believed this program to be dp,,qervirig of con-
              tinued I'@,IP support.

              Recommendation:  Approval 1: time and amount requested

              Direct Costs Only:    Ist Year             2nd Year             3rd  Year
                                   @14,872                 -0-                  -0-


              Project Yi'16 - A Traifti.n@, ProRram for Personnel o
                                                                _pre,- n Healtlll r@(-,
                            Ins..tittitions
              LriLa.q    The Cof)-@'iii.ttee responded positively to  what  they  perceived
                         to be  a  unique  educational  effort  on  the  part  of  a  regional
              medical program in that it is aimed at the many levels-of sul,)professioiial
              personnel where policies set down by leadership must be translated into
              action and xqliere breakdowns in communication frequently occur.  The
              rcvie,@.,r-,rs further recognized  the  regionalizati,on  inherent  in  a  program
              that  would  bring  together  people  from  lic@alth  care  institutions   though-
              out t@ItL@ state to -vyorlc out common problems. They were pleased to see the
              commit ent of the Oregon Association of Hospitals to continue this pro-
              gram after the period of PIMP support and were well satisfied with the
              overall design of the program.

              Recommendation:  Approval I - time and amount requested

              Direct Costs Only:       lst Year            2nd Year          3rd Year
                                       $44,503             $28$829            $14,843




                                                                                00012 7/70.1











                                      StM4ARY OF FUNDING RECOI-R.IENDATIONS



                  ect                      01-Year       02-Year-        03-Year           Total
             (#12 R    Requested)          ($14,872)      (-O-)-                         ($14,872)
             #12 R    Recommended           14,872          -0-            -0-             14,872
             (#16    Requested)            (44,503)     ($2,", '@9)      (14,843)        ($88,175)
             #16    Recommended             44,503        2b,-")Q         14,843           88,175


            (Total Requested)              (59,375)      (28,829)        -(14,843)      (103,047)
             Total Recommended             $59)375:      $28,829         $14,843        $103,047




















                                                                        RMPS/GRB/7/6/70

















            9                                                              0                                                              0









                                  REGIONAL MEDICAL PROGRAMS SERVICE
                            SIJMMAT',Y OF AN OPI,'RATIONAI, GRAN'I' AI'Pl,[(:AI'ION
                                    (I IlrivLl.e-ed  Coiiirrttin@i-(-ation)


                   l@f(,() RE(',IO"iAl, 14E])ICAI, PROGRAM RM 00065  7/70.1 (formerly 3/70.1)
            university of Puerto Rico                      February 1-970 Review Committee
            Medi(,al Sciences Campus                       March 1970 Council
            P.O. Box 4509                                  June 1970 Review Committee
            San Jtjan, Iluerto Rico

            .I:Irogram Coordinator:  Adan Nigaglioni, M.D.


                ra@
            Period:         lst  Year      2nd  Year         3rd  Year         Total

            Direct Costs    $618,756        $496,173         $515,410          $1,630,339
            Indirect Costs     78,630         83,811-           88,oo2            250,443


            TO'I'Al,        $697,386        $579,984         $603,412          $1,880,782


            fil.S'I'ORY:  On June 1, 1969 Puerto Rico entered its second year continuation
                      of planning activities, with a total award of $232,857.  As a
            result of affirmative action of the National  Advisory  Council  at  its
            meeting on May 26-27, 1969, a "Core Supplemental" award  in  the  amount  of
            $94,281 was made to support two new  programs:  (1)  establishment  of  a
            Bic)stati.stics Section ($54,636) and (2) establishment of an  Office  of
            Information and Public Relations  ($39,645).  Both  activities  have  now
            been absorbed into  Core  staff  responsibilities.

            A site visit was made on September 30 - October  1,  1969  to  determine
            if the region, based on one year's planning  experience,  was  ready  to
            become operational.  The team visited the San Juan City Dispensary No. 18,
            as well as the new Community Health Center at  Guaynabo,  the  new  hospital
            under construction at Mayaguez, and the  Health  Department  Hospital  at
            Ponce. With many years of experience in  various  kinds  of  health  delivery
            service, the Commonwealth of Puerto Rico is now launching a plan to
            integrate the private and public sectors  of  medicine.  This  will  have
            great significance for RNP and HSMHA. From  a  total  of  eight  operational
            projects, six were recommended for funding, and this recommendation was
            endorsed by both the Review Committee and Council.

            Following a negotiation meeting on January 30, 1970,  with  the  region,  an
            operational award was issued effective March 1, 1970  in  the  amount  of
            $846,000 with commitment for the second and third years for the same amount.
            Upon receipt of revised budgets from the region, the distribution of these
            monies among Core and appropriate projects will be determined.




            PUERTO RICO ILMP                       -2-                      RM 60065  7/70.1


            Project #9 - Communilzy Approach to Combat Cancer in Ponce.             lst   Year
                           This program will be based at the Ponce Oncologic        $335   173
            Hospital in Ponce, which-is the metropolitan area, with a
            population of 162,300, in the southern part of the island.  The Ponce
            region covers seventeen towns which are covered by the Ponce Oncologid
            Clinic, and all  will  be  covered  by  the  proposed  Cancer  Information  Centers.

            The Ponce Clinic  was  established  about  twenty  years  ago,  and  is  certified
            by  the  American  College  of  Surgeons.  There  is  a  Radiotherapy   Department
            with a  cobalt  machine  and  a  modern  laboratory.  Under  construction  and  soon
            to be opened in the area of the Ponce Medical Center, is a $1.5 million
            50-bed hospital with facilities and equipment for treatment of cancer.           This
            was built under the auspices of the Association to Combat Cancer.

            'Elie project would establish three Community Cancer Detection and Early
            Diagnosis Clinics throughout the area now served by the Ponce Oncolog@c
            Clinic.  About 1,500 patients each year may be treated             (1) in th6'
            Oncologic Clinic four  days  per  week;  (2)  in  Damas  Hospital  (Womens  Hospital)
            in Pon6e two days a week; and (3) in the Community General Hospital in
            Guayama (Santa Rosa Hospital) two days a week.

            Physicians  and  allied  health  personnel  will  participate  in  cancer  management
            conferences,  weekly  cancer  seminars,  workshops,  etc.   A   community   health
            education program  will  be  developed  and  will  involve  trained  social  workers.

            Six Cancer Information Centers will be located in neighborhoods indicating
            the greatest need, and it is hoped  these  will  be  able  to  reach  90%  of  the
            adult population.

            Ponce as the base is a natural  selection  since  it  is  one  of  the  three  basic
            service  regions  of  the  Department  of  Health.  The  Cancer  Information  Centers
            will  be  established  in:  Adjuntas,  Patillas,  Arroyo,  Yauco,  Santa   Isabel,
            and Guayaina.

            Each Center will be staffed with one or two Family Health Workers to cover
            a municipality, (with  a  total  of  eleven)  conveniently  located  in  each  town,
            accessible to urban as well as rural residents.  These will serve as
            community  meeting  places  with  activities  such  as  conferences,   institutes,
            workshops,  seminars,  etc.,  not  only  for  professionals,  but  for   technical
            personnel as well.  Referrals will be to the Cancer Detection and Early
            Diagnosis Clinic of persons who show signs or symptoms of cancer.

            Famil@,., 'tl(@.aitli Workers will receive two months training at the Puerto  Rico
            '.1edicai  Center,  with  additional  in-service  training  twice  monthly.   They
            will be  knowledgeable  in  community  resources  and  will  coordinate  with  other
            health and social agencies, especially public health nurses.

            'Fhe region has attempted to utilize the private sector in its choice of:
            Santa Rosa and Damas Hospitals, both private non-profit institutions.
            Through the passage of  Public  Law  56,  indigent  patients  will  be  able  to'use
            these private medical facilities with the government reimbursing institutions






                                                 -3-                      RM 00065    7/70 .1



           for Lliese services.


           Ir@ii..ni-ng activities will be based at the Ponce Onco-Logic- Hospital  and
           I.,rc.,I@l.iiiinary inquiries indicate the required number of recrui.ts will. be
           ziv;t:l [@il)le. Weeklv cancer seminars are. planned with joint participation
           oJ- all- three centers and staff of the treatment center.     These seminars
           Will take advantage (:Pf existing clinical material-  in  the  treatment  center
           [or case presentations. Any interested community pliy,,3ic@Lan  will  be  able  to
           participate in a monthly day-long  course  at  the  Treatment  Center,  and  it
           is hoped to reach at least 72 physicians per year through this course.

           i, Ival(iatLon measures  will  involve  several  sources  of  measurement--trainees,
           teachers in the  continuing  education  program,  staff,  patients,  and  other
           participating community  agencies.  Core  staff  will  assist  in  the  design.

           Staff requirements  will  be  28  professionals  and  sub-professionals,  about
           I.]. of @,lhom will be part time. Duties and  responsibilities  are  included,  as
           well as curriculum vitae of personnel already committed to the program.

           The project directors view this  program  as  self  sustaining  in  the  future
           through funds accruing through Public Law  56,  as  well  as  private  fees  from
           patients who are able to pay.

           2iid Year:  $245,648                       3rd Year:  $254,002


           Project #10 - Proposal for a Community-Family Prevention               Ist  Year
                          Program on Stroke.  The program will be based            $194,403
           in the Guaynabo Health Center, located approximately 10 miles
           southwest of the Medical Center  in  San  Juan  with  good  access  roads.  The
           Center has a total of  22  hospital  beds  offering  general  medical  services.
           Planning for the program  resulted  from  the  cooperative  efforts  of  the
           Section of Phys:Lcal Medicine and Rehabilitation of the Department of Surgery,
           the Section of Neurology  in  the  Department  of  Medicine,  University  of
           Puerto Rico School of Medicine, and the Guaynabo Health Center.

           The Program Directors have organized  the  project  based  on  a  study  conducted
           by Dr. Sanctiez-Longo and his associates  in  which  a  10-year  experience  with
           cerc-brovas(@tilar accidents at t e University Hospita  was recor e

           For the most part,  patients  with  hypertension  or  otherwise  predisposed  to
           stroke, are not effectively  managed  anywhere  in  the  island.  Most  cases  are
           handled by general  practitioners  in  small  communities  where  they  lack
           appropriate facilities  and  resources.  There  is  no  stroke  registry  to
           identify, accumulate and analyze data about patients.  There is no intensive
           (-are unit for the treatment and  demonstration  aspects  of  a  stroke  program
           anywhere in Puerto Rico, and there is no educational program for the
           community, practicing physicians or allied health personnel.  Further, there
           is no existing program  or the early detection and    'diagnosis  by  angiograp  y
           or other dia gnostic procedures for stroke patients.




             L)UL@"K'['() l@ICO l@MI?

                                    into six components:     (1)  Public   Health   Education
             'I'lie program is divided                                  (4)   Follow-up    Cl.inics,
             Servi es, (2) Screening Clinics, (3) Stroke Stations,                                           V.
                c                   rvi-ces,  and  (6)  C  ntinuing   Education   Activities.
             (5) Home Health Aide Se                    0
                                                ar will  be  served  in  the   Screening   ClIinics,
             Approximately 200 patients per ye
             mainly between the ages of 45-54, and the program will reach approximately
             100% (30,000) of  the  adult  population  of  Guaynabo  by  means  of  a  Public
                                                                        dinated throu       the
             Health Education Program.  These services will be coor                    gh
             ress  radio, television., civic clubs, and volunteer agencies, particularly
             p
             the Puerto Rico chapter of the American Heart Association.
             'Pwo Screening Clinics  will  be  established  at  the  Puerto  Rico  Health  Ce nter
             and in the Guaynabo Health Center for the community in general.  The clinics
             will be held daily  at  the  University  Hospital  under  the  leadership  of  a
             neurologist with the assistance of other members of the neurological staff
             of University Hospital.  Another neurologist, presently on the faculty at         the
             University Hospital, will visit the Guaynabo Health Center on Monday afternoons
             to supervise screening in that area.  A full-time physician will be assigned
             to the clinics.
             The  Stroke  Rehabilitation  Station  will  be  established  at   the   Guaynabo Center
             with facilities for nursing and rehabilitative care.  It will have beds for
             8 patients, later increasing to 10, and under the supervision of a full-time
             physiatrist who will direct the overall functioning of the unit.  He will
             also conduct training courses for physicians and other allied health
             personnel.
             The nursing services  of  the  Stroke  Station  will  be  under  the  direction, of a
             supervisory nurse who has specialized training in the rehabilitation of'
             patientIs  with  cerebrovascular   disease.   A   full-time   physical   therapist
             an occupational therapist, speech therapist, and rehabilitation counselor
                 be recruit@d.  A social worker will interview all patients and their
             families and a psycho-social evaluation will be made of the family of the
             patient.
             A Follow-tiu Clinic will be held every Wednesday afternoon from 1:00 P.M. to
             4:00 P.M.  I'Iii@ will. be located at the Guaynabo center and conducted by the
             physiatr--'Lst for continuous evaluation of patients who have been discharged
             from the Stroke Station.  These patients will also receive other ancillary
             services and possible further referrals for other diagnostic procedures,.
             Teii lioi-,i@    Aides will be recruited, residents from various neighbo        'rhoods
             in           at a minimum high school diploma level, and preferably from
             I-o@i-i--iicome families.  They will be trained in basic nursing and physical
             therapy procedures.  They will be supervised by a registered nurse who-is
             experienced in teaching.  The aide will be able to give injections, take
             temperatures, and perform basic urine analysis and advise about preparation
             of menus.  She will accompany patients to Follow-up Clinics, encourage self-
             reliance,  be  a  resource  in  the  event  of  family  crisis,  participate  in
             community education programs, etc.
             ']'he component for Continuing Education for Medical and Allied Health Personnel





             I'tJLR'I'C) l@1CO RIMP                   -5-                        RM 00065     7/70.1



             @,ti I I k)ff(2.i- f@liort Lrziinitig courses four time,,; @.i year for  general-  practitioners
                            (.olTkll)tllli,Li@@i it) tecliii@iqtjc@@s (.,rripl.oyc@d In rehabilitation of  stroke
                         ;itid inod(@rii ii)eltiods of screening and I)r(?vention. In addition,
             ()t.iiiL@r training courses will reach about 1.00 physician, i)ur,,,es, @ocia.1-
             worl,(.@rs, vc)c@aL@Lonal. counselors and other allied health personnel.

             'i'lie i)roject's  evaluation  wi.11  be  the  overall  responsibility  of  the  Committee
             on Stroke of  the  Puerto  Rico  RMP,  as  well  as  by  the  Board  of  Directors  of  the
             project  and  the  staff  of  the  Dean  of  the  School  of  Medicine.  This  will   be
             through visi-ts to the various components of the program, written questionnaires,
             clin@ical  data,  records  of  the  Medical  Center  in  the  Guaynabo   Health   Center,
             et(,.  IL  is  hoped  to  be  able  tc,  compare  the  incidence,  morbidity,   mortality
             and  incapacity  of  stroke  victims  in  a  similar  community  not   now   receiving
             the benefits of the program.

             The project authors anticipate the continuation of this program upon
             termination  of  federal  funds  through  the  joint  efforts  of   the   Department   of
             Health  of  Puerto  Rico  and  the  University  of  Puerto  Ri.co,  Medical   Sciences
             Campus (Medical School).

             2nd Year:  $193,356                            3rd Year:  $202,503


             Project #11 - Project for Computerized Dose Distribution                    lst   Year
                             Calculations and Radiotherapy Treatment                     $89,180
             Planning for the Radiotliera2y and Cancer Division at the
             Puerto Rico Nuclear Center and, I. Gonzalez-Martinez Oncologic Hospital.
             This  urogram  will  establish  a  program   for   automated   radiotherapy   dose
             calculation  and  treatment   planning   to   provide   individualized   treatment   plans
             and  graphic  dose  distribution  for  each   radiotherapy   patient.   Such   a   program
             will  provide  optimal   treatment   planning   for   individual   patients   undergoing
             external  radiation  therapy,   and   graphic   representation   of   dose   distribution
             within the treatment volume for each Datient.


             'Fhe program will be based at the 1. Gonzalez-Martinez Hospi.tal whi.ch is
             dedicated  exclusively  to  the  care  and   treatment   of   cancer.   rhe   Radiotherapv
             and  Cancer  Division  of  the  Puerto  Rico  Nuclear  Center   and   the   Radiotherapy
             Department  of  the  Hospital,  function  as  a  single  staff   unit.   The   two
             radiotherapy  areas  at  these  institutions   enjoy   close   physical   proximity,   a
             common  Di.vision-Department  Head,  and  staff  members  who  work  i.n  both   areas
             on a monthly rotation program.

             'Flie  Radiotherapy  Department  has  a  daily  patient  census  that  ranges  from   120-
             160  cases  per  day,  with  a  patient  treatment  load  of   approximately   550
             teletlierapy  applications  per  week.  At   present   dose   information   is   determined
             by  hand  calculation  and  one  point  (central  axis)  tumor  dose  and   is   calculated
             for  every  teletherapy  field.  In   general,   complete   dose   distribution   14ithin
             the treated volume is done by hand and is reserved for a few specially
             selected cases.



          PUT]R'FO Rl('O l@MI)                                     RM 00065 7/70,1.

          'I ']le proposal. requests funds for a programmed console system and the
                                                                          The
          development of a computerized dos!-metry service in Puerto Rico.
          system will also provide for establishing a treatment planning center and
          a base of the training for radiotherapy residents in dose computations as
          well as the services of a radiological physicist for training in dose
          computation, treatment planning and computation techniques.
          Because the PC system presently does not permit its utilization for
          interstitial implant dosimetry, supplementary computer facilities are also
          requested. Such computer time would be by  subcontraIct to the Mayaguez
          Campus of the University of Puerto Rico.  This computer is an IBM 360-'O.
          The first year will be phased into 2 parts:  (1) to establish the autonomous
          mode of the PC system with concurrent utilization of the IBM 360-40 for
          interstitial implant dosimetry and (2) provide the means for renting 2
          Xerox telecopier units, one to be located at the Puerto Rica Nuclear
          Center and the other at the Ponce Oncologic Clinic.
          The second year will add a Xerox telecopier at the Mayaguez Medical Center
          and will initiate charges for services on the basis of cost evaluations
          studies so that the facility can become self-supporting.
          Funds are requested for a Computer and Electronic Technician, a Dosimetrist
          Contour Technician (2 full-time and 1 part-time).  In addition, the present
          staff of the center would devote varying periods of time to the project
          2nd Year:  $57,169                     3rd Year:  $58,905


          CRITIQUE:  February 1970 Review Committee
          GENERAL:  Tt@c rei4-o-wers found that this application was better than Precious
                   ones in documentation and @l-irected at major health problems in
          Puerto Rico as already identified by a recent site visit.  This supplement
          seems to be well phased with the other components of the operational program
          and based on a ten-year health planning program for the island.
          The application has good regionalization aspects, especially with one  project
          based at Ponce which will be the site of a second medical school in time.
          The Medical Center enjoys an acceptable level of medical practice in a  modern
          sense, and has an active renal transplant program.
          Projec" #9 - Comm nit Approach with Interagency Cooperation to  Combat  Cancer
                      Ponce.
              I UE:  The needs for trained personnel including physicians in the
                     southern portion of Puerto Rico is particularly acute.  This
          point should be seriously considered in evaluating this project, since it
          appears that the program will not bring new people to the area, but may
          further dilute the activities of the available personnel presently  performing
          medical care in this portion of the island.




            PUERTO RICO RMP                   -7-                         RM 00065 7/70.1

            The project should be viewed as a strengthening of the impressive medical
            center in Ponce which was compared to an iceberg with only portions of its
            potential clearly visible.
            One weakness of the budget portion is the failure to identify personnel,
            which indicates that it is highly likely that the budget will provide total
            or partial funding for people already performing the medical care in the
            Region, and who are already in short supply.  The competitive position of this
            application would be tremendously strengthened if the Region could assure
            that the budget will provde only for new people brought into the Ponce area.
            The request for $20,000 for consultant services appears to be unrealistic in
            that available consultants are already overburdened.  Overall, the budget
            appears to be rather diffuse and difficult to evaluate with large amounts
            earmarked for equipment and sub-contracts.
            The evaluation program is vague, but this is understandable since the
            research associates who will determine the program have apparently not
            been selected.  The Oncologic Clinic does have good background information
            of the population on cancer rates, stage and morbidity, and it would seem
            that a suitable evaluation program could be devised with appropriate
            direction.
            Generally, the program appears to be far too all-inclusive for the
            available medical and allied health personnel in the Ponce area.  The Region
            does not indicate how the project would increase medical manpower, and
            from the evidence presented, it would appear that it would produce a further
            dilution of available limited manpower.
            RECOMMENDATION:  Deferral for site visit for further evaluation of all
                             concerns outlined above.


            Project #10 - Community Family Prevention Program on Stroke.
                I UE:  There was no question in the minds of the reviewers that the
                       need for such a program in stroke is critical in Puerto Rico.
            The limited economy, the shortage of personnel and facilities, the
            fatalistic attitudes and chronically low expectations to misfortune, make
            the locale eminently suitable for the Guyanabo area.
            The proposal is well planned and the interlocking relationship of the
            medical school and the district health center hospital at Guyanabo was
            believed to be strengthening to the program.  The operational aspects
            have been clearly thought out and the relatively small population is an
            advantage in that it will be easy to reach.  If personnel are available,
            this total operational system between the university and a community
            hospital should have a real impact on stroke.
            Another interesting aspect of the project is that it will      aril  put to
            the test the success of the public education aspects, along with the




                                                                     RM 00065 7/70.1
         PUERTO RICO PMl'
         professional education of practitioners. The project will stand or  fall
         on this key component. The-reviewers noted that this important point  is
         well understood by the applicants.  They noted that if Puerto Rico
         succeeds in stroke care, general health care will improve, provided
         personnel and facilities become proportionately available.
         The reviewers found the budget somewhat perplexing.  While a new project-,@,.-
         of this.sort would entail a higher cost outlay in an effort to treat
         100.patients yearly, screen an unknown number of the population of 60,000,
         and mount an educations  program, the direct cost of approximately $200,000,
         and a projected $800,000 over a three-year period, was considered excessive.
         It is quite obvious  that almost every category of professional staff will
         require funding from RMP funds.
         Since this multiple-faceted project will not be able to be initiated all
         at once, the reviewers felt that it would be wiser to phase the operation',
         giving priority to education and the stroke station first.  This procedure
         should prove to be more economical.
         The evaluation impact of training and education is well-planned.  The  health
         evaluation portion is less developed.  Although data components are given,
         there is no differentiation between medical record entries and hard data':
         relevant to searching inquiry to achievement of various objectives and
         sub-objectives.  on the whole, this section is the weakest, but at the same
         time the reasons for its weakness are understandable.
         it was noted that there is no provision for data processing and publication
         except for a rather large, unexplained budgetary allotment of $2,500 times
         3 years. Apparently no thought has been given to data analyses and  devel-op-
         ment of conclusions.
         The project deser,-@s serious conS4deration in that it makes an impressive
         effort to organ4@ze existing facilities into a regional plan to improve
         and initiate prevention, diagnosis, comprehensive care, and lay  professional
         education. The organization was believed to be feasible and  the  operational
         components are appropriate for the program content as presented.
         One problem may be in the recruitment of personnel although it was noted
         that the applicants are in contact with professional organizations which
         will probably extend assistance. The budget appears to be  inflated  for
         such a small population and this deficiency may be mitigated somewhat by
         postponing certain features, and phasing in others.  For example, screening
         of ttie population for stroke proneness may prove to be an undesirable
         burden at first in the presence of known personnel shortages.  Another
         suggestion was that the regional stroke station (the rehabilitation unit)
         can be initiated under the co-investigators aegis thereby saving for the
         first period on salaries for a full-time neurologist and a  physiatrist.
         RECOMENDATION:  Deferral pending a site visit to explore all of the
                          concerns and reservations as outlined above.





            PUERTO RICO RMP                   -9-                        RM 00065 7/70.1


            Project #11 - Computerized Dose Distribution, Calculations and Radiotherapy.

               I UE:  The Committee noted that the two radiation therapy centers
                      for which this project is to be used are both well  established,
            have active clinical programs, and see sufficient patients to warrant a
            budget as requested. However, it was noted that some reductions  could  be
            effected by reducing the Project Coordinator's salary (or even eliminating
            it), and by utilizing only one dosimetry and contour technician instead of
            two. It was further suggested that travel could be reduced, and  for  the
            first year at least the computer time could be reduced from about $12,500 to
            about $8,000,  There was agreement that the project would improve the quality
            Of radiation treatments as well as ttie accuracy of the dosage.
            The application fails to justify the need for the program  console.  Also,
            the Region failed to document the present role of this equipment in clinical
            radiation therapy as well as the experience of others with it.  The question
            of the need for individually plotted isodose distributions on every patient
            was also raised; it is also not apparent why an isodose plotter should  be
            needed.
            Cervical cancer rate is high in Puerto Rico. There is a busy  service  of
            from 120 to 180 patients census. The department is headed by a  good  man.
            The request for technical items will need to be translated into how  much
            the ability to plot doses with this equipment and trained technical  staff
            will contribute to the treatment capability as well as the educational
            process and capability.
            The project raised the policy question of the computer aspects of the program
            and pointed up the need for a computer policy for adequate evaluation  of
            this project.
            RECOBMNDATION:  Deferral for a site visit to obtain more information regarding
                             the feasibility and the soundness of the proposal and  to
            clarify the concerns as outlined above.


            MARCH 1970 COUNCIL ACTION:

            Council concurred witb Anril Commi.ttee's recommendation with one exception:
            With respect to project #10, council agreed to delegate to the site  visit
            team the authority to investigate it further and, if appropriate, to
            recommend its approval and determine the level of award (not to exceed the
            amount requested).

            SITE VISIT - May 18-19, 1970:
            A report will be available at the Committee meeting.



            PUERTO RICO @IP                        -10-                     RM 00065    /70.-.l


                                  OPERATIONAL STATUS      (DCO)


            PROJECT
            NUMBER     TITLE                                                        FUNDING  LEVEL

                       Core                                                         $   213,386  (7-mo)

                       Northeast Regional Pediatric Medical Program
                       for Cardiovascular Diseases                                      2509000

            2          Program in Hematology, Cancer Chemotherapy and
                       Blood V)anking                                                     84,533

            3          Center  for  Management  and  Treatment  of                      2569168
                       Chronic  Pulmonary  Diseases  in   Children

            4          Education  Program  in  Diabetes   Mellitus                        80,000
            5          Central Cancer Registry                                            50,000

            6          Dial Access                                                  Disapproved

            7          Education and Training of RNs and MDs
                       in Intensive Cardiac Care                                        200,000

            8          Stroke Demonstration Unit      Ponce                         Disapproved


                       TOTAL                                                        $1,134,087




                                FUTURE RECOI*IENDED LEVELS


                                        02                      03
            Core                  $  316,942             $  347,596

            Projects                  873,818                852,468


                                  $1,190,760              $1,200,064









                                                                                    DRMP-2/6/70.





                                                         A  Privileged  Communication





                              ,SUMMARY OF REVIEW AND CONCLUSION OF
                                    JUNE 1970 REVIEW COMMITTEE


                              PUERTO RICO REGIONAL MEDICAL PROGRAM
                                          RM 00065 7/70.1

                         FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


          General:  The Committee member who chaired the site visit team of May 18-19,
                    1970, reported to the Review Committee the  team's  findings  and
          recommendations. (The report of the site visit is attached.)  The region is
          just beginning to move into full operational status.  The  PR/RMP  has  ton-
          tihued to refine its organizational framework under the  leadership  of  Dr.
          Cristino Col6n, who is doing an effective job.  Planning  for  RMP  program
          outreach beyond the San Juan Medical Center area hat been a special Achieve-
          meftt in view of the centralization of private and university-based medical
          retources in San Juan. The site team was impressed  by  the  development  of
          major interest and enthusiasm of lay and medical  leadership  in  Guaynabb,
          Ponce, and to a lesser extent, in Guayama.  Dr.  Nigaglioni,  the  official
          Coordinator, is more and more a background figure, but  very  valuable  for
          hit present planning for health aides and other allied  health  training  in
          some of the Commonwealth's junior colleges, such as in Ponce.
          Membership from the lay power structure for PR/RMP R.A.G. members and sub-
          committee members is still insufficient. The  private  medical  sector  in
          San Juan seems inactive in planning  or  participation.  Industrial  medical
          facilities developing at the Phillips plant and the  Chem-strand  plant  at
          Guayama appear to be outside of RMP planning efforts.  In  Ponce,  on  the
          other hand, there is excellent lay liaison through  the  Oncologid  Clinic,
          supIported by the southern branch of P.R. Cancer Society,  and  through  Di.
          Rodriguez' cardiovascular and renal dialysis and  transplant  program  which
          has wide and enthusiastic public support (750+ dialyses for 35-40 patients
          in the Ipast two years). The excellent private  medical  sector  support  and
          participation in Ponce district projects is quite different from the
          Capital Area indifference and bodes woll for effective RMP pro  jects in this
          area.
          The nursing profession is still being slighted as An ally  in  health  plan-
          ning, in traineeships, and in operational programs as instructors.
          The site team cited the desirability of  broadening  operational  programs
          to effect a multidisciplinary approach particularly in training activities.
          The next eighteen months will be critical for the success  of  the  PR/RMP
          within the $1,200,000 annual budget for eleven projects  and  an  Additional
          nine ready for submission to RMPS. It is believed  that  a  ceiling  already
          his been reached in the 50 - 100% participation of physicians for the
          leadership and development of these programs.  Future  site  visitors  must
          ;aiefully evaluate whether salaried time on the job in RMP programs is
          really being effectively applied by named participants.




                                                                      RM 00065 7/70.1
            PUERTO RICO RMP                    -2-


                                          to Combat Cancer in Ponce
            Project #9 - CommuLlit
                     This project seems to be the most effective thus far in cancer,
            Critiqy_t:
                     and builds on an already existing bridge between the Oncologic
            Hospital in Ponce and the Medical Center in San Juan.  It is obvious that
            Ponce is developing @apidly as a center for cancer treatment.
            The Hospital, which is situated across the street from the District
            General Hospital, provides an excellent focal point for the management
            of all forms of cancer in a multidisciplinary fashion.  The Program
            Director is an active young man, well-trained and dedicated to the success
            of the project.
            The Committee endorsed the recommendation of the site team that the inclu-
            sion in the non-professional staff budget of a number of full-time individuals
            seems illogical at this point, since it will be a while before the program
            is staffed and underway.  Furthermore, the eleven family health workers who
            are requested at 100% would be better designated as trainees, since this is
            the true purpose of their involvement.
            It was noted that the regional junior college in Ponce now under construction
            will be a source of training of technologists and therapist assistants.
            The other two participating hospitals--the Damas Hospital in Ponce and the
            Santa Rosa Hospital in Guayama, about an houres drive from Ponce, are actively
            involved and enthusiastic about the program.  A new hospital will be com-
            pleted in 1971 for the Damas facility, which is presently quite crowded.  The
            Santa Rosa Hospital recently has been renovated and is quite well-designed.
            The Director, Dr. Garcia, reported that they are presently working out
            arrangements with two new large plants of the Phillips Petroleum Company and
            one of their subsidiaries, Fibers International, for a prepaid medical plan
            which the company proposes.  Once the program for cancer detection and early
            diagnosis is underway, some patient care costs could be defrayed through
            a third party payment plan.
            The budget was believed to be unrealistic for the first year.  Justification
            for the number of nurses, stenographers, social workers, health educators,
            etc., is difficult.  On the other hand, the health educator and the group
            of family health workers (trainees) will be essential during the first year,
            but it was doubted that eleven could be recruited immediately.
            The request for consultants appeared excessive, but these are in fact instruc-
            tors to be utilized in training programs, and the recommendation was that
            they be so designated on a part-time basis.  As for equipment, the suggestion
            was made that an attempt be made to get partial support from local sources.
            The laboratory services request was also recommended at a reduced level, as
            well as travel, publication, etc.  Other costs in connection with materials
            for the clinic, alterations, telephone and rental of information center
            offices ( in the satellites) were thought to be reasonable and necessary for
            a program of this magnitude.
            While there was no representative of the local Cancer Society or of the
            nursing group present during the site visit, the regional representatives




                                                      3                         065  7/70.  1
            PUERTO RICO RMP                                                RM 00


            assured the team  that  the  former  group  is  largely  responsible  for  the
            planning and development of the program as well as the new hospital.

            The reviewers noted  that  there  is  an  established  tradition  in  Puerto  Rico
            in the field of Oncology  and  this  is  now  being  translated  into  a  sub-
            regionalization  of  the  PR/RMP.  This  is  emerging  in  the  Cancer  Chemotherapy-
            Hematology Program,  in  the  Radiation  Therapy  Program,  and  with  the  intro-
            duttio6 of hew methods in radiation physics.  This should generate interest
            in the centralization of the radiation therapy efforts on the southern side
            of the island.

            Recomm6ndAtion:  Approval I - to be conditional upon a revision of the
                               budget in line  with  above  suggestions  And  spelled  out  in
            mote detail in the site visit report.

                     First Year            Second Year            Third Year
                     $160,000               $1609000              $160,000


            Project #10 - Community Family Prevention Program on Stroke And its
                           Incapacitating Complications.

            CritiquO:  The  reviewers  noted  that  this  project  was  submitted  to  the
                        February/March  1970  cycle,  which  recommended  approval  in  a.
            reduced amount of approximately $100,000, to be based on further review
            by a site visit team.
            The Chairman of the  team  reported  to  the  Committee  oh  the  excellent  Guaynabo
            area involvement  and  support  for  this  program,  (which  includes  the  Mayor)
            And referred  to  the  original  operational  submission  which  included  a  totally
            unacceptable  stroke  project,  The  leadership  of  this  present  project   has
            not demonstrated  strong  administrative  ability,,  and  this  was  considered  a
            potential threat  to  its  success.  A  young  neurologist  who  will  finish  his
            training this month,  Dr.  Hettor  Casas,  beginning  July  1,  1970  will  spend
            a  year  in  Houstdt  for  further  training  in  cerebrovascular  disease.  Upon
            his return to Guaynabo, he will be directly involved in the project.  Also,
            the region  has  reported  its  identification  of  a  full-time  dir6ctor--a  lady
            physician.

            The reviewers believed this  to  be  an  excellent  area  for  a  pilot  training
            center to which other areas  in  the  island  could  look  as  a  stroke  resource.
            The@project  directors  were  receptive  to  the  suggestion  that  the  requested
            four practical nurses and four nurse assistants should be considered as
            trainees rather than permanent personnel.
            There is a  desperate  need  for  aides  to  physiatrists  throughout  the  island.
            There are fifteen physiatrists  in  Puerto  Rico,  two  of  whom  are  in  Mayaguez
            and two in Ponce.  One  resident  is  committed  to  join  the  Guayh'abo  program
            upon completion of  his  training.  The  site  team  noted  that  an  entire  area
            in the basement of one  of  the  hospitals  visited  in  connection  with  the  Ponce
            project, was  fully  equipped  for  physical  medicine  and  rehabilitation,,  but
            totally  unused.  The  Director  reported  that  two  physiatrists  who  had  been



                                               -4-                 RM 00065 7/70.1
           PUERTO RICO FU4P

                                                     had to give up because  they  could
           coming from San Juan on a part-time basis
           not get any occupational or physical therapist assistance.   it is rea  sonable
           ,to anticipate that the training of one or two aides from the Ponce area  will
           make a significant contribution to the Ponce neu@-ologist's ability to  mount
           a stroke program. This suggestion was well received by  the  Guaynabo  stroke
           staff.
           The budget request was difficult to assess. It was  concluded  that  Guaynabo
           is an ideal location for this program, where patients can be  found,  brought
           into the clinic and some attention directed to the managment of  the  problems
           of hypertension and stroke. Optimal opportunities  exist  for  rehabilitation,
           and evidence of the interest of the community at large was demonstrated. (The
           Municipal Government will provide an Emergency Services Program to  be  coor-
           diratedwith this project and also provide minibuses.)
           The region has submitted a revi sed budget in line  with  the  recommendations
           of the site team.
           ,Recommendation: Approval I - with the following conditions: (1)  RMPS  staff
                            is to examine the revised project plan to be  based  on  the
           suggestions of the site team and in line with the revised budget already
           submitted; (2) a technical site visit should be made during  the  first  year
           of operational status of the project to see what progress has  been  made  in
           line with the suggestion of the site team. Note: One Review  Committee  member
           dissented.
                     First Year              Second Year              Third Year
                      $112,163               $135,741                 $165,214
           Project #11 - Computerized Dose Distribution Cale--ulation in RadiotherAU.
                         Treatment Plannin .
           ,Critique: The reviewers noted the outstanding  leadership  of  this  project
                      under Dr. Victor Marcial.  The regionalization and multidisciplinary
           aspects of the project were well received. The  Puerto  Rico  Nuclear  Center
           has had centralized services in association with the Oncologic Hospital
           since  1966.  It also serves the Virgin Islands.  Its three main services are
           amalgamated-education, research and radiation therapy.  In addition to
           serving two-thirds of the island (1,300 cases yearly),  ten  medical  students
           and a varying number of technicians and physicists  are  trained  each  year.
           The reviewers heard that eventually there will  be  three  radiology  centers
           in Puerto Rico--San Juan, Ponce and Mayaguez.  The Dosimetry Service@, Program
           will provide a teaching opportunity in radiation therapy not  only  for  local
           trainees, but those outside the San Juan area as well.  Cooperative arrange-
           ments are under negotiation with the groups in Mayaguez and Ponce.
           The Chairman of the site team reported to the Committee that between the
           time of the submission of the present application and  the  site  visit,  Dr.
           William Powers of Washington University, representing  the  American  College
           of Radiologists, visited Dr. Marcial for several days.  It was on Dr. Powerso
           advice that a request was made for additional equipment in the form of a




          PUERTO RICO RMP                        -5-                  RM  00065   7/70.1

          simulator, which Dr. Powers felt would be essential for the proper operation
          of this program. As a consequence,  additional  funds  are  requested  for  pur-
          chase and maintenance ol this equipment.

          In addition, Dr. Powers recommended that,  instead  of  five  part-time  radio-
          therapists, one half-time radiotherapist and one half-time radiation
          physicist would be more  appropriate.  The  reviewers  concurred  with  the
          recommendation  of the site team that this would be mote realistic.

          The requested program console is already in  use  in  thirty  radiation  therapy
          centers in the U.S., Great Britain and  Canada.  The  Puerto  Rico  group  will
          be a part of a national cooperative  which  will  evaluate  this  approach  to
          radiation therapy.

          The site team Chairman reported that the  application  for  this  program  was
          reviewed in terms of the seven points agreed  upon  by  the  Ad  Ho  Group  to
                                                                          'IO C
          consider projects of Radiation Dosimetty  Services,  appointed  at  the  request
          of@Council and chaired by Dr. Michael  Brennan.  It  was  the  consensus  that
          more cancer patients will probably  receive  better  isoddse  distribution  with
          ,the program console, and the service will provide  a  teaching  opportunity  in
          radiation th6tapy. Also, there  is  excellent  follow-up  and  assurances  that
          the dosimetry services will become  self-supporting  as  third  party  payments
          take over some of the  costs.  The  excellent  relationship  of  this  program
          to existing chemotherapy and other cancer programs in Puerto Rico was noted.
          Finally, the Review Committee agreed that  the  cooperative  group  effort  in
          the national program will be furthered  by  having  this  program  console
          ay*.i-lable:
          -The Addendum prepared as a result of the  revised  budget  covers  mainly
          the professional support at $27,876 for  a  half  time  radiotherapist  and
          a half-time radiological  physicist.  One  dosimetry  and  contour  techni-
          cian will be required the first year,  and  an  additional  one  the'second
          and third years for Ponce and Mayaguez.  The equipment costs are mainly
          for the first year,, with minor expenditures to  add  the  two  satellites  in
          Ponce and Mayaguez the second and third years.
          The program console, isodose plotter and the  simulator  unit.'  should  be
          considered as a whole.  Commensurate with previous recommendations, the
          site@@teAm.recommended  and the reviewers concurred that RMP support
          be limited to no,moie than 50 - 75% of  this  request,  with  the  balance
          to be contributed from local sources.  Further, the Review Committee endorsed
          the ted6mmendgtioh that income generated during  the  three  years  of  support
          should be put in escrow in order to regain some  of  the  personnel  and  main-
          tenahte costs.  Cost sharing aspects will be investigated by Dr. MarciAl and
          Dr. Colon.

          On the basis of the well-planned regionalization aspects of this      project,
          its excellent professional'direction, its future self-supporting      feature,
          and its role in the broadly-based cancer  program  for  Puerto  Ricoi  the
          Committee recommended its approv  al.

          Recommendation: Approval@l - Conditional  upon:  (1)  Submission  of  a  revise
                            request which  will  incorporate  the  additional  equipment
          and increase in percentage of effort  of  professional  personnel  as  referred



            PUEF,TO RICO RMP                        -6-                     RM   00065   7/70.1
            to above; (2) plans for phasing of the project         - organizing and de-bugging
            the first six months, adding Porice and Mayaguez commensurate with the
            project's  progress;  (3)  plans  to  obtain  some  (25%  -  50%)   local   support
            for the program console and related equipment; and (4) the region's plan
            for managing funds accruing to the grant to be used to help offset
            maintenance   and   personnel   costs.

                       First Year                  Sedond    Year          Third Year
                       $160,936                    $67,436                 $73,636




                                         SUMMARY   OF RECOMMENDATIONS


            Project                      01-Year                02-Year              03-Year
                                                                $160,000               $160,000
                                          $160,000
            #10                          112,163                   135,741              165,214
            #11                          .160,-930               .457  -4a             72,636-

                   Total                 .@433i@099             6363,177               $398,850












                                                                        RMPS/GRB/7/15/70





                                                                A PRIVILEGED COMMUNICATION
                                                                RM 00065
                                     SITE VISIT REPORT
                           PUERTO RICO REGIONAL MEDICAL PROGRAM

                                     May 17-19, 1970



                 REVIEW COMMITTEE
                 Henry M. Lemon, M.D., Chairman, Professor of Medicine, University
                                                of Nebraska, Omaha, Nebraska
                 CONSULTANT
                 William S. Fields, M.D., Professor of Neurology, University of Texas
                                         School of Neurology, Houston, Texas
                 RMPS STAFF
                 Jessie F. Salazar, Public Health Advisor, Grants Review Branch
                 Frank Nash, Public Health Advisor, Programs Assistance Branch

                 REGIONAL ADVISORY GROUP
                 Hector F. Rodriguez, Chief, Department of Medicine, Ponce District
                                           . Hospital, Ponce, Puerto Rico
                 Praxedes Norat, Department of Health, San Juan, Puerto Rico

                 PUERTO RICO REGIONAL MEDICAL PROGRAM
                 Adan Nigaglioni, M.D., Coordinator, Chancellor, Medical Sciences
                                       Campus, University of Puerto Rico
                 Christino R. Colon, M.D., Associate Coordinator
                 Merlin D. Lugo-Faria, M.D., M.P.H., Associate Coordinator-Health Services
                 Orlando Nieves, Administrator
                 Marta Tejada, Social Investigator
                 Norris Blake, Director, Office of Information
                 Project #9 - Inter-Agency Cooperation to Combat Cancer in the Ponce Region

                 Hamlit Hazim,, M.D.
                 Jose N. Correa, M.D.
                 Raul Armstrong M.D.
                 Jorge Garcia Guzman, M.D.
                 William Bracer, M.D.
                 Joaquin Robiri, M.D.
                 ProJect #10 - Community Family Prevention Propram on Stroke

                 Carlos Armstrong Ressy, M.D.
                 Luis P. Sanchez Longo, M.D.

                 Project #11 - Computerized Dose Distribution

                 Victor M. Marcial, M.D.
                 Theodore Villafana, M.D.





                                                                A PRIVILEGED COMMUNICATION
                                                                Rm 00061



                                         SITE VISIT REPORT
                                PUERTO RICO REGIONAL MEDICAL PROGRAM

                                          May 18-19, 1970


             BACKGIIOUND: The first supplemental operational application, composed of
                        three new projects was submitted for review by the February/
             March 1970 cycle. The reviewerg(Technical Panels,  Review  Committee,
             Council and Staff) found the application better than the previous  ones
             in documentation and direction toward major health problems in Puerto Ricot
             as identified by a previous site visit in September 1969.  The application
             was found to be well-ohased with other operational components and based
             on a ten-year health planning program for the Island.
             There were a number of areas on each of the three projects,  however,
             that raised a number of questions. in some instances,  the  budgetary
             requests  seemed over-ambitious (Project #9, Ponce Cancer Program).
             This project seemed to be too all-inclusive  for present available med-
             tial and allied health personnel in the Ponce area.  There were other
             concdrns about the evaluation program.
             Deliberations about Project #10, Community Family Prevention Program on
             Stroke also raised some perplexing questions regarding the budget.  The
             proposed phasin of the program may present some burdens in  terms  of
                            9
             available manpower. Other problems inherent with the  organization  for
             such a program were noted, as well as how the region plans to go  about
             the health evaluation portion.
             In view of the findings of the previous site visit and the  recommendation
             of the National Advisory Council which evaluated the region's first  pper-
             ational proposal in December 1969, this project was conditionally approved
             with authority delegated to a site visit team to review all concerns and
             questions raised by the reviewing bodies and recommend an appropriate
             amount to be awarded.
             The final project (#ll) for a Computerized Dose Distribution,  Calculation
             and Radiotherapy Program, also presented some questions, some of  which
             were technical and others largely concerned *fth insufficient budgetary
             documentation.
             The application received a recommendation of "Deferral" for a site
             visit to investigate and clarify all of the concerns of reviewers. Pro-
             je@ts #9 and #11 must be re-submitted to the review cycle of  June/July
             1970. Project #10, conditional upon appropriate alterations  in  budget
             and program as recommended by the site visit team, will be awarded from
             FY 1970 funds.
             GENERAL: The site team met first at the regional  headquarters  with  Core
                       staff. Both Doctors Nigaglioni and Col'on reported on  recent
             developments in the region and gave an updating of the operational program.
             The region has continued to refine its organizational framework with the





            PUERTO RICO RMP                         -3-                       RM   00065


            establishment of new Task Forces and by adding four new Regional Advi-
            sory Group members, all  representative  of  the  health  consumer.  These
            are an industrialist from the Ponce area,  and  insurance  executive,  a
            banking executive and an attorney.

            Insufficient recruitment still exists in the  lay  power  structure  for
            RMP RAG members, and  sub-committee  members.  The  private  medical  sector
            in San Juan seems quite inactive in planning or participation.         Indus-
            trial medical facilities developing at the Phillips plant and the Chem-strand
            plant at Guayama appear to be outside of RMI? operational planning.  In Ponce,
            there is excellent lay liaison through  the  Oncologic  Clinic,  supported  by
            the southern branch of the P.R. Cancer Society, and through Dr. Rodriguez'
            remarkable cardiovascular and renal  dialysis  and  transplant  program  which
            has wide and enthusiastic public support (750+ dialyses for 35-40 patients
            in the past 2 years). The  excellent  private  medical  sector  support  and
            participation in Ponce district projects is quite different from the capital
            area indifference and argues for strong development of the RMP projects in
            this area.

                    .1
            Dr. Colon has developed more and more  effective  planning  for  RMP  program
            outreach beyond the P.R. Medical Center area, a real achievement in
            view of the centralization of private and university-based medical
            resources in San Juan, and the physician  deficiency  outside  of  San  Juan.
            We were all impressed by the development  of  major  interest  and  enthusiam
            of lay and medical leadership in Guaynajbo, Ponce, and  to  a  lesser  extent
            in,Guayama. Dr. Nigaglioni, the  official  coordinator,  is  more  and  more
            a background figure but very valuable for  his  present  planning  for  health
            aidesa',@allied health training in some  of  the  Commonwealth's  junior
            colleges such as at Ponce.

            Dr. Colon has much of the responsibility for maintenance of enthusiasm
            for RMP planning and projects, which  declined  with  recent  budget  cuts
            and delays in funding.  Dr. Correa in Ponce will become, along with
            Dr. Hector Rodriquez, major allies in RMP work on a regional basis,
            particularly since they are truly full-time physicians in their institutions
            in areas of cancer and heart disease.

            The nursing profession is still being slighted as  an  ally  in  health  plan-
            ning, in traineeships, and in operational programs as instructors.  It
            is suggested that the next site visit include  a  nursing  educator  to  see
            how the traditional attitude of doctors towards  nurses  in  P.R.  can  be
            changed.

            Mr. Norat, representing the Department  of  Health,  expressed  an  interest
            in the training of health aides, since the  Department  is  not  budgeted  for
            such training. The high school graduate  is  Puerto  Rico's  largest  source
            of allied health manpower.
            Another general issue raised by the site  team  was  the  desirability  of
            broadening, where possible, operational programs so  as  to  effect  a  multi-
            disciplinary approach. For  instance,  the  Cancer  Registry  project  could,
            once organized and running well, be broadened  to  include  other  diseas@@s
            as a collaborative effort. Also,  training  programs  should  have  some
            indentifiable common base which could be adapted to new areas and programs.






               I



             PUERTO RI CO RMP                              -4-                RM  00065


             The Model Cities  and  Family  Planning  Programs have been involved in   plan-
             ing for training of home  health  aides  for  the projects under  review  and
             the team heard abouta:proposed'program in  nutrition  which  is  being  planned
             jointly with the Model Cities program, and  a  similar  nutrition  program  for
             rural areas.

             If the present three proposals are funded, it would seem that the      next
             18 months will be critical for the success of the PR/RMP, since they
             will have to develop the  operational  aspects'of  11  projects  involving
             $1 200,000 annual budget. It is  believed  that  a  ceiling  has  already  been
             reached, for the involvement of 50  -  100%  participation  of  physicians  for
             the leadership and development of  these  programs.  Plans  which  look  excel-
             lent on paper appear unrealistic when  one  views  the  limited  physician
             participation in "full-time"  Health  Department  or  University  activities
             compared to their splintered  individual  private  practice  efforts  into
             which costs of living have forced most of  the  professors.  Dr.  Colon  and
             Dr. Nigaglionl. are trying to develop,group family medical practice,
             initially in -the Guaynabo area, in order to  develop  more  continuity  of
             medical coverage, in both  private  and  public  sectors  of  medicine.  Future
             site visitors must carefully evaluate whether  salaried  time  on  the  job
             in RMP programs are really being effectively applied by named participants.
             Dr. Lemon and Dr. Fields consulted  with  Dr.  Anatol  Raventos  in  Washington
             D.C., with Dr. Paul Meadows of the  Eppley  Radiation  Center  in  Omaha,  with
             Dr. Giulio D'Angio, of Memorial Hospital for Cancer and Allied Disease, and
             with Marilyn Stovall, M.D. Anderson Hospital  subsequent  to  the  site  visit.
             All consultants agreed that additional  half  or  full-time  assistance  for
             radiation dosimetry would be equally  as  important  as  the  program  console.
             The latter is important chiefly in training and in improving the flexibility
             of planning radiation therapy.  Miss Stovall stated that her institution has
             been programming for the  Puerto  Rico  radiation  facility  for  sometime.  In
             her opinion the console requested by Dr. Marcial is          sophisticated
             and will need large computer back-up, which is available.


             Project # 9 - Community Approach to Combat Cancer in Ponce.
                            This project was reviewed by the site  visit  team  on  the
             second day of the visit in the Ponce  Oncologic  Hospital,  the  Dames  Hos-
             pital and the Santa  Rosa  Hospital  in  Guayama.
             The team met first with the Program Director,  Dr.  Hamlet  Hazim  and  the
             Program Coordinator,  Dr.  Jose  N.  Correa,  and other members  of  the  staff.
             The hospital  has  been  occupied  three  months, and it was  pointed  out  that
             the facility  resulted  from  nineteen  years  of planning since  he  took  over
             the responsibility  for  the  cancer  program  in the Ponce District.







            PUERTO RICO RMP                        -5-                    RM 00065

              Tt,e Program Director is a very vigorous and active young man, who is
              dedicated to making the project an effective one.
              The Ponce Oncologic Hospital, which is situated across the street  from  the
              Dittrict General Hospital in the Medical Center, provides an  excellent  fo-
              cal point for the management of all forms of cancer in  a  multidisciplinary
              fashion in the southern part of the island of Puerto Rico.
              it was pointed out that the request to RMP in for support  of  training  and
              not service.  Dr. Armstrong, o surgeon, noted that the courses will be
              aimed at physicians who are working at health centers.
              To the question of where the project directors would placepriorities
              for the program, the response was first for professional  (medical)  person-
              nel and then on the training and education of the public,  The planners
              view the gap between professional evaluation of  cancer  and  the  beginning
              of treatment as crucial, and it is hoped to give general practitioners,
              theough such training, an opportunity to do  more  "specialized"  treatment.
              They pointed out with obvious feeling and justification, that if such a
              program in early diagnosis in cancer detection is initiated, some  means  of
              treating the increased load which would be generated must be provided.
              Two general practitioners, one to be located at the Dames  Hospital@and  the
              other at the Santa Rosa Hospital in Guayama have been identified. A  third,,
              on a part-time basis, would be located within the Oncologic Hospital  Clinic
              itself. This is a lady physician (Drs. Whitney) who has  not  practiced  for
              some years, but now that her family is grown up,, she would like  to  become
              more active. The surgeon,, Dr. A=strong, will devote 20%'time  to  the  pro-
              ject.  Also present was Dr. Garcta, who is involved in the hematology project
              (#2) which is operational. Rounding out the program is  a  pathologist,  who
              is located at the laboratory in the Damao  Hospital,  the  radiologist,  and
              the head and neck surgeon, An executive secretary  is  also  requested,  and
              support for an Administrative Coordinator of activities of this  cooperative
              endeavor. The gentleman is already identified  and  was  the  administrative
              officer who was actively involved in planning  of  the  Oncologic  Hospital.
              The site team is of the opinion that the inclusion  in  the  nonprofessional
              staff budget of a  n'umber of full-time individuals seems  illogical  at  this
              point, since it will take quite a while to get a program of this nature
              staffed and underway. Purthemote,  the  eleven  family  health  workers  who
              are listed at 100% would be better designated as  trainees,  since  this  is
              the true purpose of their involvement.
              The team learned that the University of Puerto Rico has started  a  regional
              Junior College in Ponce and that construction is  already  underway.  It  is
              anticipated that from eighteen months to two years will be necessary
              for completion of the first units and that such a facility could be






                                                                   RM 00065
              PUERTO RICO RMP               -6-

              integrated into the teaching efforts that could be a resource for training
              of technologistoand therapist assistants.
              A tour of the facilities led to some discussion of some alteratiors-of a
              room adjacent to the operating suite which could be used for minor  our-
              gery.  This appeared to be feasible and practical to the site teas.
              The need for a 250 KV therapy unit was broached and it was  pointed  out
              that the available unit located at the Damao Hospital is  quite  ancient
              and inadequately housed. There is such a unit in  the  Oncologic  Center
              in San Juan and presently not being utilized by Dr. Marcial and his
              group. The region will explore the possibilities  of  transferring  this unit
              to Ponce, even temporarily, for more effective use.
              Thi site team visited the Damao Hospital in Ponce, where it was  learned
              that the present facility is over fifty years old, with every square inch
              utilized.  .4 new building, now under construction is expected to be ready
              f6r occupancy by the end of 1971. The Pathology  Laboratory,  whose  Dir
              ector is a partidipant in this project, is modern, spacious and appeared
              to be well-administered.
              After finishing the portion of,)fhe site visit located in the  immediate
              Ponce area, the site team drove to Guayama, tihich is about an hour's
              drive from Ponce, to visit the Santa Rosa Hospital.  This  is  a  modern
              facility which was recently renovated and repainted.  The  Outpatient
              Department and its laboratory facilities seem  to  be  understaffed  and
              underutilized. On the other hand, of the 45 inpatient beds,  40  were
              occupied and nurses actively engaged. The building  is  well-designed
              so as to permit nurses easy access and eight of activities.
              It was learned from Dr. Garcfa, the director of this  hospital,  that  a
              large plant was recently opened by the Phillips Petroleum  Company,  and
              another by their subsidiary, Fibers International. This  complex  has  a
              prepaid medical plan and is presently working out arrangements with this
              hospital. Dr. Garcfa feels that once the-program  for  cancer  detection
              and early diagnosis is underway, some patient care costs could be defrayed
              through a third party payment plan.
              Although most of the effort at the beginning will be directed  toward
              private or part-paid patients, it is hoped that as the  program  becomes
              more effective, it will have an outreach into  surrounding  rural  areas
              where some of the indigent patients could be contacted and brought in for
              examination.  This is the function earmarked for the two home health aides.
              The budget appeared to be unrealistic ($300,000) for the first  year  in
              view of the time that will be required to get such a  project  underway,
              The justification forthe number of nurses, stenographers, social workers,
              health educators, etc., is difficult.  It is questionable whether such a
              group of pe6ple would be necessary before the third year.  On the other
              hand, the health educator and the group of family  health  workers  (who
              should be considered as trainees rather than full-time  employees)  will
              be essential during the first year.  It is doubtful, however, that eleven
              -can be recruited immediately.





              PUERTO RICO RMP                -7-                    RM 00065


              one health educator would seem to be sufficient for the first year, and
              once the project is moving, a second one at the Guayama Hospital would
              be advisable.  During the first year, it seems unlikely that more than
              50% of one social worker's time would be utilized, but during  the  second
              and third years, should probably be full-time.
              One question was clarified during the budgetary discussions.  The  request
              for consultants, which appeared excessive, are in fact instructors  to  be
              utilized in training programs, and the site team recommended that they  be
              so designated on a part-time basis.  It is believed that $5,000 will be
              sufficient for the first year for such clinical instructors, and  approxi-
              mately $10,000for consultants in other specialties such as  urology,  etc.
              Consultant fees at the Damao and Santa Rosa Hospitals are justifiable
              provided they are engaged as part-time instructors.
              As for the equipment budget, the suggestion was made that an attempt be
              made to get partial support from other local sources.  The team recommended
              that support for either purchase of rental of the 250 KV unit be reduced to
              50% of the request.  This does not imply that the early detection and
              diagnosis aspects would not be enhanced by such equipment--rather that
              local sources should be tapped for at least half the amount.  The same
              rationale applies to the equipment for use in the minor surgery suite once
              the alterations have been accomplished.
              The laboratory services request, which includes routine work, biopsies, etc.,
              was recommended at a reduced level, as were budget requests for travel,
              publication costs for printing educational material, and office  supplies.
              Materials for the clinic, alteration costs, telephone and rental of infor-
              mation center offices are reasonable and necessary for a program  of  this
              magnitude.
              The visitors recommended that every effort be made to bring  in  trainees,
              not only from the Ponce and Guayama districts, but also from outside these
              areas, with the expectation that they would return to their locales and
              provide some outreach. It was also recommended,that some attempt  be  made
              to integrate the educational efforts of this project with the stroke  pro-
              ject. This could be the means of holding the physicians'  interest  for  a
              longer period and on a continuing basis, as well as utilize some of the
              available talent in the adjoining District Hospital. This  would  includit
              Dr. Rodriguez, Director of the Cardiovascular Service and Dr. Carreras, the
              full-time neurologist, both of whom have been involved with  RMP  planning
              for the Ponce area.
              Another indication of the interest of the Ponce District Medical Association
              was demonstrated by the presence of the President at the  initial  meeting
              with the site visitors. With the available group  of  vigorous  physicians
              and surgeons in Ponce, the time is probably ripe for the development of  a
              more comprehensive continuing education program for physicians, allied
              health personnel and, in particular, nurses.
              There has been an undercurrent of resentment on the part of  Ponce  physi-
              cians that major RMP attention has been directed toward university-centered





              PUERTO RICO RMP                  -8-                   RM 00065


              activities in San Juan to the neglect of needs of physicians  around  the
              periphery. Notable expeptions to this are Doctors Hazim  and  Correa  who
              attest to the excellent liaison arrangements that do exist between the
              Ponce group and the fLan Juan headquarters. This is attributable  to  the
              dedicated efforts of Dr. Christino Coldn, who was born and brought up  in
              Ponce and knows that area well.  He knows persounally many of the doctors
              there and enjoys a good working relationship with them.
              The site team was disappointed that there was no representation of the
              local Cancer Society or of the nursing group.  The,regional  representatives
              assured the vistors that the Cancer Society is indiaed very much interested
              in the project and were in fact largely responsible for the planning  and
              development of the program and the new Oncologic H6spital.
              It was evident that the District Medical Association is supportive of this
              project and is engaged in the development of a unified  District  medical
              library which will be organized in collaboration with the Catholic Univer-
              sity.  Provision will be made for 250,000 volumes.
              There is an established tradition in Puerto Rico in the field of Oncology
              and it would appear that this is now being translated into a  sub-regionali-
              zation of the Regional Medical Program. This is emerging  in  the  Cancer
              Chemotherapy Hemotology Program9 in the Radiation Therapy Program,  with-the
              introduction of new methods in radiation physics and in the Early  Diagnosis
              and Cancer Defection program on the south side of the island.  Hopefullyi
              within the next two or three years, there will be a greater degree df
              cooperation in these ventures with a resultant impact on the cancer problem.
              The site team agreed that this project should generate interest in the
              centralization of the radiation therapy efforts on the southern  side  of
              the island.  The effort on the part of Dr. Correa and his staff to upgrade
              patient care in this field shc,iuld permit private patients, as well as
              indigent ones, a better means of receiving proper treatment.  In this
              event, it is likely that private radiation therapists, most of  whom  are
              trying to do both diagnosis and therapy and having difficulty in doing both,
              would be likely to get out of the therapy field and devote their attention
              to diagnosis.
              Project #10 - Community Family Prevention Program on Stroke and its
                            Incapacitating Complications.   The site visit team visited
              the Guaynabo District Health Medical Center in the afternoon and met with
              project directors, the medical director of the center, the Mayor of Guaynabo
              and other staff.
              It was pointed out by the site team that this proposal had progressed through
              the review process to the National Advisory Council, where a conditional
              approval was given in a reduced amount of approximately $100,000,  to  be
              based on further review by a site visit team.
              The proposal involves the establishment in the Guaynabo Health Center an
              eight-bed stroke unit to which patients from the area could be admitted,
              and, if necessary, transferred from there to the university hospital for







                                                                          RM 00065
             PUERTO RICO R14P                       -9-


             further diagnostic evaluation.  The Guaynabo area has a population of between
             80 to 90,000, representing considerable spread in economic status.  There
             are some indigent patients, some middle class and some fairly wealthy people
             in this community situated about 10 miles from San Juan.
             Dr. Luis Sanchez Longo gave an overview of the project including its progress
             since its submission. Complicated cases identified in Guaynabo will be  sent
             to the university hospital, where every effort will be made to get them started
             on a rehabilitation program and sent back to Guaynabo for long term care and
             follow-up. It was evident that Dr. Sanchez Longo was thinking first  of  the
             improvement of his program within the University Hospital and secondarily-
             of the satellite health center.  He introduced the subject, but emphasized
             the need for improved facilities in the x-ray Department.
             In addition to a neurological screening clinic to be held daily in the morning
             at the university hospital, a similar clinic will be held in Guaynabo on
             Monday afternoons.
             In discussion of the required personnel, it was difficult for the site  team
             to understand the roles of the requested staff. It was learned that a  young
             neurologist, Dr. Hector Casas,,who will finish his training this month, will
             be going to Houston about July 1, to spend a year for further training in
             cerebrovascular disease.  He will then return to Puerto,Rico, where he  il
             be affiliated with the project.  The site team found difficulty in seeing
             how one year's training in techniques he will learn in Houston will  be
             applicable to the Guaynabo project, but on the other hand, he could be  very
             useful in the university stroke program4
             Dr. Sanchez Longo reported on additional contact  made with agencies in  the
             San Juan area to assist in creating the concept of such a stroke center in
             the community.  There are eleven neurologists in Puerto Rico, all in San
             Juan except Dr. Carreras, who lives and practices in Ponce.  In an attempt
             to get physicians involved, one day symposia are planned for  intensive
             training in stroke.
             In the discussion about continuing education, it was evident that the project
             directors and other physicians connected with the program were thinking
             mainly in terms of physician education, albeit the application includes a
             curriculum for training of allied health personnel. V&ile  the  request
             would appear adequate for a stroke unit on a 24-hour basis, they have not
             addressed the problem of getting people trained to offer some kind of
             service to the community at large.
             The project directors were receptive to the suggestion that the four
             practical nurses and four nurse assistants be considered as trainees  rather
             than permanent personnel. They could be given on-the-job  training  and
             rotated at whatever interval the doctor in charge feels is appropriate for
             them to obtain sufficient  knowledge to be useful as home health aides.
             Over the period of time that the site visit was in Puerto Rico, traveling
             and working closely with the Program Coordinator and the Associate Coor-
             dinator and other Project personnel, the concept of the Guaynabo project





               PUERTO RICO RMP                          -10-                      RM   00065

               as a pilot training center, to which other areas in the island could look
               as a stroke resource, came more clearly into focus.  The site team is con-
               vinced that Guaynabo would provide an excellent area for such a pilot study.
               This will be impossible however, without some readjustment in the present
               plan and without dedicated  direction.  The  region  has  identified  such  a
               person--a lady physician--Dra.  Lluveras.  She  was  unable  to  be  present,
               but was represented by Dr. Lop@z.
               The site team learned that there are about 15 physiatrists in Puerto Rico,
               two of whom are in Mayaguez and two in Ponce.  One resident is committed
               to join the program upon completion of his training.
               There is a desperate need for aides to physiatrists in various parts of the
               island.  During the site team's visit to the Santa Rosa Hospital in Guayama
               (Project #9 - Cancer Program for Ponce), an entire area in the basement of
               the hospital was equipped for physical medicine and rehabilitation.  All
               of the expensive equipment has been pushed over to one side to make room
               for storage.  In this instance the Director of the Hospital indicated that
               he had had two physiatrists who had been coming  out  on  a  part  time  b.asis from
               San Juan,- but gave up because he could not get any help from occupational
               or physical therapists.
               While the site visitors were in Ponce the subject was discussed with Dr.
               Carreras, a neurologist who had submitted  a  stroke  project  in  the  first
               operation application  which  was  disapproved.  Dr.  Carreras,  appeared  to
               be very upset about the  disapproval.  It  was  explained  to  him,  however,
               that he should endeavor to work  out  a  regional  plan  in  collaboration
               with the project in Guaynabo, with the assistance and coordination of
               Dr. Colon and his staff.  It seems reasonable to anticipate that the train-
               ing of one or two aides from the Ponce area would make A significant cons
               tribution to Dr. Carreras' ability to mount a stroke program.  Dr. Carreras
               seemed pleased and receptive to this suggestion.
               The site visit team toured the facilities at the Guaynabo Center which had
               been open for three months. There  did  not  seem  to  be  much  activity--at
               about 3:00 P.M. on a Monday afternoon.  There were no patients in the
               out-patients department and very few in-patients.
               The plan for an eight-bed unit seemed unrealistic to the site team.  From
               population statistics and available manpower, two or three beds could be
               kept filled and this would seem more feasible.
               The site team had difficulty in  assessing  this  project  in  terms  of  the
               budget request. Gueynabo  is  an  ideal  location  for  this  program,  where
               patients can be found, brought into the clinic and some attention directed
               to the management of the problems of hypertension and of the stroke patient.
               Optimal opportunities exist for rehabilitation which would be possible in
               this setting.  Evidence of the interest to the community was demonstrated
               by the presence of the Mayor throughout the entire proceeding.  He indicated
               that he is most anxious that his program get underway at the earliest
               possible moment.  Also, the Mayor reported that the Municipal Government






           PUERTO RICO RMP                                               RM 00065


           of Guaynabo will operate an Emergency Services Program which will be
           coordinated with this stroke proposal; minibuses will be provided by  the
           city for such emergency services.
           The question of funds accruing to the grant from other sources, which  would
           free some monies for use elsewhere in the grant was discussed.  For instance,
           the trainee stipends recommended could be utilized elsewhere.  Another  idea
           which the Coordiantor will purtue is training aides for private nursing homes.
           He stated that such training is nonexistent in Puerto Rico and that  care
           provided by such long term care facilities is inferior.
           The site team recommends that RMPS staff examine whatever plan  the  PR/@P
           decides upon, within the framework of the revised budget as recommended by
           the site team and already submitted, and further, that a technical  site
           visit be made during the first year of operational status of the  project
           to see what progress has been made in its development along the lines
           suggested by the visitors. the team believed that it is essential  to  the
           success of this program that it be initiated along the lines discussed
           with the project directors. Otherwise, it will probably not  achieve  the
           goals and objectives the region envisions for it.
           Project #11 - Com2uterized Dose Distribution Calculation in  Radiotherapy
                         Treatment Plann@. This project Was  presented  by  Dr.  Victor
           M. Marcial, who is the.director.  The application was considered in light of
           the Ad Hoc site visit evaluation on Radiation Dosimetry Services.

           The Puerto Rico Nuclear Center has had centralized services  in  association
           with the cancer hospital since 1966. It also serves the  Virgin  Island.
           The three main services are now amalgamated--education, research and  radia-
           tion therapy, under the direction of Dr. Villafana, who is a medical  physi-
           cist. The AEC support has diminished to the point that the Center  can  no
           longer make long range plans.
           In addition to serving two-thirds of the island, which represents approximately
           1,300 cases a year, ten medical students are trained each year, and a varying
           number of radiology technicians and physicists.

           Dr. Marcial's group has been active in developing a network of  radiology
           centers in Puerto Rico--eventually there will be three such  centers--in
           San Juan, Ponce and Mayaguez. At present they do not have  the  personnel
           to staff all three.  The new group will be using an interdisciplinary pro-
           gram--chemotherapy, radiation therapy, surgery, etc.
           The Dosimetry Services Program will provide a teaching opportunity in radia-
           tion therapy not only for local trainees, but those outside the San Juan area
           as well. Cooperative arrangements are under negotiation with the  groups  in
           Mayaguez and Ponce.

           Between the time of the submission of the application and the site  visit,
           Dr. William Powers, of Washington University, representing the  American
           College of Radiologists, visited Dr. Marcial for several days. It  was  on
           Dr. Powers' advice that the application was revised to include  additional





            PUERTO RICO RMP                        -12-                 RM 00065


            equipment in the form of a simulator unit, and an increase in percentage
            of effort of project staff. This addendum was presented for the  site  team's
            consideration.
            Dr. Powers recommended that, instead of five part-time  radiotherapists,  one
            half-time radiotherapist and one half-time radiation physicist would be
            more appropriate. The site team concurred that this would be  far  more
            realistic. For the present, Dr. Villafana will assume the  function  of
            radiation physicist. It was also learned the following day  in  a  succeeding
            discussion of this project with the Director of the Oncologic Hospital,  that
            he would also lean very heavily on Dr. Marcial for  assistance  in  radiation
            physics.
            The addendum prepared as a result of the revised budget covers mainly
            the professional support at $27,876 for a half-time,radiotherapist  and
            a half-time radiological physicist. One dosimetry and  contour  techni-
            ciah will be required the first year, and an additional one the  second
            and third years for Ponce and Mayaguez.  The equipment costs are mainly
            for the first year, with minor expenditures to add the two satellites
            in Ponce and Mayaguez the second and third years.
            there was discussion concerning the computer usage via a  telephone  link  to
            Mayaguez. The programs have apparently been written  (La  Jolla,  California)
            although it was unclear what language was being used, and  whether  the  plan
            was compatible with the IBM 360-40 system which is presently in operation  in
            Mayaguez.  It would seem reasonable to expect that programs are available
            for this purpose, but it did not seem that a sufficient amount of  considera-
            tion had been given to the matter of how the software would be compatible
            with available hardware.


            The requested program console is already in use in thirty  radiation  therapy
            centers in the U.S. There was a meeting attended by Dr.  Villafana  of  users
            of this console recently.  Dr. Villafana feels that the console would enhance
            considerably the capability in terms of patient load and the ability to
            pro4uce information about dosimetry at a lesser cost and  more  rapidly.  The
            Puerto Rico group will be part of a national cooperative which will  evaluate
            this approach to radiation therapy.
            When questioned about the relationship of this program  to  the  chemotherapy
            and other cancer therapy program, Dr. Marcial pointed out  that  during  this
            particular visit he was wearing one hat, while on another day, he might  well
            be wearing another.  As Director of the Medical Services in the Oncologic
            Hospital at the Medical Center, he is responsible for directing all  forms  o
            cancer therapy, and all endeavors in cancer will be integrated.

            Dr. Marcial made it clear he was not going to evaluate a  comparison  between
            radiation therapy and chemotherapy, but rather evaluate  split  dosage  where
            he would treat, then wait a while, then treat again. He  believes  he  is  in
            a better position to advise at the end of a specific period than  to  try  to
            do too much in all of the fields.





           PUERTO RICO RMP                       -13-                     RM 00065


            The application was reviewed in terms of the seven points agreed upon by the
            Ad Hoc Group to Consider Projects of Radiation Dosimetry Services (appointed
            7t- Th-e request,of the National Advisory Council,  February  1969,  and  chaired
            by Dr. Michael@'Brennan). More  cancer  patients  will  probably  receive  better
            isodose distribution with the program console.  The service will provide a
            teaching opportunity in  radiation  therapy.  There  already  exists  a  coopera-
            tive arrangement among Ponce, Mayaguez and San Juan in radiation therapy.
            There is excellent follow-up in Dr. Marcialls treatment program.  Dr. Marcial
            assured us that the dosimetry  services  will  become  self-supporting  as  third
            party payments take over some of the  costs.  In  the  beginning  only  two
            institutions will be participating across the island.  Also, the site team
            believes that Dr. Marcial's cooperative group effort in the national program
            will be furthered by having this program console available.

            The program console, isodose plotter and  the  simulator  unit,  should  be
            considered as a whole.  Commensurate with previous funding, the site team
            believes that RMP support should be limited to no more than 50 - 75% of
            this request, with the balance to be contributed from local sources.  Further,
            income generated during the three years should be  put  in  escrow  in  order  to
            regain some of the personnel and maintenance costs.  The readjustments in
            the budget, incorporating those items to  be  retained  from  the  original
            budget and those changes suggested by Dr. Powers,  as  well  as  the  site  team,
            were discussed fully with Dr. Marcial.     The cost sharing aspects will be
            investigated by Dr. Marcial and Dr. Colon.

            On the basis of the well-planned regionalization aspects of this project,
            its excellent professional direction, its future self-supporting feature
            and its role in the boradly based  cancer  program  for  Puerto  Rico,  including
            professional and technical training,  the  site  team  recommends  approval
            on the basis of a revised budget as discussed with the Project Directors
            and Program Coordinator.


                                   SUMMARY OF RECOMMENDATIONS

            Project                         Amount Requested(d.c,)        Amount Recommended (d.c.'

            #9    Cancer/Ponce                     $335,173                    $160,000
            #10    Stroke/Guaynabo                  194,403                     112,163
            #11    Computerized Dosi-
                   metry                            161,000                     16C@,9,@i6

                               TOTAL               $690,576                    $433,099







                                                              RMPS/GRB/7/15/70








                                REGIONAL MEDICAL PROGRAMS SERVICE
                    SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                   (A Privileged Communication)

         SOUTH CAROLINA REGIONAL  MEDICAL PROGRAM                   RM  00035   7/70.1
         Medical College of South Carolina                          June 1970 Review Committee
         80 Barre Street
         Charleston, South Carolina  29401

         Program Coordinator:  Vince Moseley, M.D.

         Requested
         Program
         Period              Ist  Year         2nd  Year        3rd  Year           TOTAL
         Direct Costs         $454,769          $409,767         $497,988        $1,362,524
         Indirect Costs         88,232           108,408          122,539           319,179


         TOTAL                $543,001          $518,175         $620,527        $1,681,703

         History: The  Region's  initial  planning  year began on January 1, 1967 and
                   was supported by two awards totaling $123,527 (T.C.).  An award
         of $379,246 (T.C.) was made for the.second year of planning 1/68-12/68.

         The Region became operational on August  1,  1968  following  the  submission
         of 20 projects and a site visit in April  1968.  An  award  of  $931,507  (T.C.)
         was made for support  of  seventeen  projects.  Shortly  thereafter,  two
         core awards totaling $559,342 (T.C.) were made to continue planning
         activities during the 03 planning year (1/l/69-12/31/69).
         Supplemental applications consisting of 10 new projects, #21-#31 excluding
         #27 which was withdrawn, were considered  during  the  February  1969  Review
         Cycle and deferred for a site visit.  The site visit was conducte  in
         may 1969.  All ten projects, plus two supplements to ongoing projects #15
         and #16, were returned to the May  1969  Review  Cycle.  Both  Committee  and
         Council Actions were consistent with  the  recommendations  of  the  site
         visitors. Six projects were  recommended  for  approval,  two  for  non-approval
         and two for revision.  The requests for supplemental funds for project #15
         and #16 were disapproved.
         In July 1969 staff reviewed the continuation application for the 02
         operational year which requested continued  support  for  fifteen  of  seventeen
         originally funded projects. As a result  of  that  review  and  a  subsequent
         request for use of unexpended funds  to  support  approved  but  unfunded
         projects, the Regionwas awarded $I,066,091 (d.c.).      Of this., $202,256.
         (d.c.) was awarded core for the seven-month period I/l/70-7/31/70, $843,835
         (d.c.) was awarded  for 15 ongoing projects for the period 8/l/69-7/3i/70
         and three approved but unfunded  projects  for  the  period  11/l/69-7/31/70.
         This award served to incorporate planning  and  operational  funds  into  one
         grant period.
         An application including two new projects  was  reviewed  during  the  August
         Review Cycle, but neither project was approved.




          SOUTH CAROLINA Regional Medical Program         -2-          RM  00035   7/70.1
          The Program Coordinator is Vince Moseley, M.D., who has served in this
          position for approximately j year. The RAG  consists  of  65  members,  largely
          physicians, of which 20 represent the 10 districts designated by  the
          South Carolina Medical Society. The  Hospital  Association  has  strong  repre-
          sentation with six representatives.  There are 15  Members-at-Large  consisting
          primarily of M.D.'s and what appears to  be  other  professionals.   Appare@tly
          these people represent the consumer  interests.  Minority  group  representation
          is not identified, however, itshoulj be noted the site visitors in  April  1969
          cited minority group under-representatic,n as a concern.
          The regionalization process is proceeding as scheduled with area program
          development offices being opened  recently in Columbia, Spartanburg and
          Florence. Each office is staffed by a part-time  coordinator  and  a  full-time
          secretary.
          See attachment for summary of projects currently  being  supported  and  status
          f projects not funded.
          0

          Background of Present Application
          Of the three projects in this application, two were considered during
          previous Review Cycles and were returned to the Region for revision and
          resubmission. The first, Project #36 -  Chronic  Respiratory  Disease
          Traininp, Program, was returned as a result of Committee members' belief
          that the project was rather unrealistic and global in its plans.  They
          questioned the capability of the institutions to do  all  that  they  proposed.
          The educational impact was considered poor and the curricula  for  the
          professional trainees not clearly defined.  Some  doubt  was  expressed  as  to
          the qualifications of the personnel to be involved in the development and
          operation of a two-year program in inhalation therapy or to  carry  on
          continuing education for other professions  involved.  The  equipment requests
          were considered unreasonable and unnecessary for either  teaching  or providing
          service. There was an obvious lack of coordination  with  Schools  of Allied
          Health which also provides Inhalation Therapy Training.
          The Committee had learned that the State Department of  Health  had   submitted
          a similar project to the Atlanta PHS Regional Office for 314 E support
          which had been disapproved.  It was recommended these  agencies  get  together.
          Project #37 -     nar Care Risk Factor Educational  and  Screening  Project  was
          returned because of Committeels concerns over  the  following  points:  1)  the
          amount of $8.50 for laboratory services was considered excessive.  It was
          advised the applicant look for more competitive services such as those
          provided by United Pathology Laboratories of Portland,  Oregon;  2)  who  would
          benefit most by the project, the physician who  receives  the  patient  or  the
          general public? 3) would a survey for hypertension be  a  preferred  method  to
          that outlined?  The Committee believed the proposal required extensive
          revision, including documentation of the relationship  to  existing  cardiology
          clinics, more adequately delineated follow-up procedures and  a  description  of
          the plan for community out-reach.  Furthermore,  the  patient  did  not  appear
          to have continuous identity. It was noted  there  were  physician  and  patient
          educational benefits, but no provision for follow-up or of controlled
          Therapeutic Trial.





           SOUTH CAROLINA Regional Medical Program     -3-            RM 00035 7/70.1
           Present Application
                                                                               Requested
           Project #35 - Comprehensive Coronary Care Program  for  Commun@     First Year
                        Hospitals in the Central Subregion of South Carolina.    $106,900
           The ultimate goal of this project is to improve the care of  patients
           with acute coronary disease by developing intensive coronary  care
           services in community hospitals of the Coastal  Subregion.  During
           the first year four unspecified hospitals will be enrolled and  an
           additional four hospitals will be enrolled the second year.  By
           the end of the third year, the coronary care programs should be
           well established and self-perpetuating.
           Eligible hospitals, with the assistance of SCRMP core staff,  will
           develop a comprehensive coronary care plan.  Training courses in
           the comprehensive programs will include: Hospital-wide CPR Training,
           conducted through the SCRMP CPR project of the South Carolina Heart
           Association; Coronary Care Nursing Supervisor Training,  conducted
           through the SCRMP Coronary Care Nurses Training Program of the
           University of South Carolina School of Nursing; Coronary Care
           Familiarization Training for Nurses, organized in each hospital
           and assisted by core staff; Individualized Training for Coronary Care
           Medical Directors, provided by the Division of Cardiology at the
           Medical University; In-Service Continuing Education for Coronary Care
           Nurses, assisted by core staff and University's Coronary Nurses  Train-
           ing Program.
           Communication systems will be established for consultation of  EKG
           transmission, linking each,participating hospital to the  Coronary
           Care Unit at the Medical University Hospital or other major hospitals
           having a comparable well established CCU. A proposed  patient  registry
           is to provide the data required for evaluation of the effect of the
           program on patient care.  In addition evaluation plans are provided
           for the educational program, communications systems, impact on  patient
           care and for Cost/Benefit Analysis.
           The major items of the $106,900 first year budget are personnel,
           $84,900, and arrhythmia monitors and EKG strip recorders, $15,000.
           Second Year:  $120,173                       Third Year:  $107,857
                                                                                  Requested
           Project #36 - Comprehensive Respiratory Disease Training  Program.     First Year
                         This, the Region's first respiratory project,  proposes   $179,487
           the establishment of a central laboratory/educational facility  at
           the Charleston V.A. Hospital to be used in conjunction  with existing
           hospital-based facilities for demonstration of care, diagnosis, and
           management of patients with pulmonary disease. It will  provide  a
           focal point for training of physicians and allied health personnel in
           addition to working with patients who have pulmonary disorders  an
           offering an  interim state-wide pulmonary referral base for community
           hospitals until they develop capacity for adequate programs of  their
   0       own. A comprehensive classroom facility will be developed  as  the




          SOUTH CAROLINA Regional Medical Program         -4-         Rm 00035  7/70.1
          initial'phase of a state-wide educational program.  The facility will
          have at its disposal  8  bed-s in an adjacent wing of the V.A. Hospital  and
          beds at MUSC Hospital,and will accept patients  from  throughout  the
          State with all types of pulmonary disease excluding active TB.  Since
          many of the patients entering the unit will have respiratory failure,'
          there will also be 2 beds in the existing  intensive  care  facility
          with special monitoring facilities for  respiratory  failure.
          Within the unit will be developed two classrooms, a complete pulmonary
          function laboratory, an inhalation therapy  service,  and  pulmonary
          medicine service. The present out-patient  program  of  the  hospital
          will be located here.
          Patients will be admitted from unspecified sources to  either  out  or
          in-patient services regardless of financial status.   Third party
          payment of fees will be disposed in accordance with policies of DRMP.
          The project will implement over a three-year period a five-point
          segmented educational approach:  1) In-Unit Educational Programs will
          be offered physicians, nurses, inhalation  therapists,  and  pulmonary
          technicians; 2) staff will make lecture visits  to  institutions  and
          groups within each of the 10-state planning districts;  3)  upon  specific
          invitation, project staff will be available to visit and consult with
          any hospital concerning establishment, improvement, or evaluation of
          pulmonary services at the institutions; 4) annual seminars  will  be  held
          for physicians, nurses, inhalation therapists, and pulmonary technicians
          to cover the latest developments in the area of respiratory disease;
          5) a Data Transmission Network will be established linking community
          hospitals, physicians' offices, and  other  interested  organizations,
          agencies, or institutions into a computer atthe centra'@ program facility
          to provide immediate patient consultation services.
          Project evaluation will be carried out through the appointed
          Respiratory Disease Evaluation Committee which will receive all
          evaluation data, site visit the project at least  once  a  year,  and
          meet in a body during the tenth month of each project  year  to  determine
          if the project is fulfilling objectives completely and  at  the  projected
          rate,
          Second Year:  $93,156                         Third  Year:   $196,361
                                                                                Requested
          Project #37 - Coronary Risk Factor Education and S      nin           First Year
                        Project.  This project is designed to apply   methods    $168,382
          for identification and reduction of coronary disease risk   factors
          through project services  which  include  specific  screening  proce-
          dures designed to cover large  groups,  project  operated  education/
          action programs, referral to family  physician,  referral  to  State
          clinics and follow-up of high risk individuals.    The  basic  concept
          involves opening an operations center at  the  University  of  South
          Carolina to initiate project services and to serve as a focal
          point for expansion of project services to a state-wide basis
          through establishment of satellite  centers,  and  mobile  screening
          teams. The operations center  will  maintain  its  own  identification
          action-follow-up @:rogram, set overall policy and procedure, and




           SOUTH CAROLINA Regional Medical Program        -5-          RM 00035  7/70.1

           act as a total resource base for the specific  "identify-action-
           follow-up" activities of the satellite operations.  Ten  satellite
           centers will be developed over the life,of the project with  two
           being developed during the first year; one in Charleston and one
           in Greenville. Each satellite will consist of a  skeleton  staff
           which will include:  a part-time medical director, secretary,
           nurse and nurses' aid.  The satellites will have the same
           identification-action-follow-up goals as the operations  center;
           however, will modify procedures to the extent necessary within
           the confines of available resources and medical  patterns.  Mobile
           screening teams and mobile education teams will be utilized in
           supplementing local program activities where necessary.  Sources
           of patients to be screened will include: referral from  physicians
           and the State Heart Clinic, County Heart Units service  organizations,
           hospitals, schools, industries and various other health  institutions
           and organizations. Screening results will be reviewed by  the  medical
           consultants and forwarded to referring physicians.  Persons identified
           as having risk factors will be placed in the education/action  program
           of the program upon referrals of their physicians.  Specific education/
           action programs include:  1) Diet and Weight Control, 2) Cigarette
           Smoking, 3) Physical Activities Programs, and 4)  Hypertension.  These
           programs will be established at the operations center and the satellite
           centers. Each individual entering the education/action  portion  will
           agree to participate in the follow-up program which will consist  of:
           1) Annual rescreening of pertinent risk factor(s), 2) "Status Card"
           made up on each individual from screening results and oral  question-
           naire, A copy of the card will be mailed to  referring  physicians
           for information, 3) Annual Education Seminars will be held  concerning
           each risk factor and will be both motivational and informative  in
           content.  The mainstay of the evaluation process will be the Heart
           Disease and Stroke Categorical review on an  annual  basis.  The
           review will be based upon: 1) Project site visits  of  Committee
           members, 2) Pro'ect progress report data (quarterly), 3)  Statistical
                          i
           data extracted from project participant flow and processes through
           the University's computer center, 4) Consultation from an impartial
           out-of-region expert in the area of coronary risk factors.  Significant
           budget items include:  Staff at $76,873, Consultant Services at $16,000,
           Equipment at $45,450, Supplies at $13,259 and Alterations and Renovations
           of a satellite center at $4,000.
           Second Year:  $196,438                      Third  Year:  $193,770





                                                                       -6-           RM 00035  7/70.1
                        SOUTH CAROLINA Regional 14edical Program
                        Summary of operational projects currently being supported  by  SCRMP.
                        Project Title & Number        Approved Project          Funded    2nd Year
                                                           Period              (direct cost only)
                                                                                            31/70

                                 Core                      3  Years                  $202,256

                        #1  York General Hnspi@
                            @oronar  Care U i              3  Years                  33,600
                        #2  Greenville Coronary            3  Years                  7,782
                                 Unit
                        #3 - St)artanburg C  ar            3  Years                  16,073
                            Care Unit
                        #5  -Universitv of South           3  Years                  49,557
                                         ar
                            Carolina C
                                 Unit
                        #6  Sparta  u   Geeneral           3  Years                  24,220
                            Host)ital Heart Clinic
                                                           3  Years                  25,748
                        #7
                              rt Clin
                        #8  Cardiop    ary  Re-            3  Years                  37,845
                            u,citation Training
                                                           3  Years                  95,501
                        #9  -Cervical Cancer  Sc
                        #10 -                              3  Years                  87,360
                        #12 -Pediatric Caanncceerr headuucczation 3  Years           109,117
                            n@d Service
                        #13 -Demonstration Project for     3  Years                  31,103
                            he Deteci                 f
                            Gastrointestin        t
                        #15 -Acute Stroke                  3  Years                  69,247
                        #16 -Stroke Rehabilitation         3  Years                  40,718
                        #18 -Chronic Hemodialysis          3  Years                  20,300
                            Demonstration Un  t
                        #20 -Health Education and          3  Years                  54,207
                             ecruitment
                                                                                 Funded lst 9 months
                                                                                 (direct cost only)
                                                                                 11/i/69-7/31
                        #25 - Central T--r Re 'str         2  Years                  27,000
                        #26 - State,4ide Radiation         2  Years                  111,750
                            Therapy ar


                                                                                     22,707
                                                           3  Years
                        #31 -

                                                                  Total            $1,066,091







                                                                  Rm 00035  7/70.1
         SOUTH CAROLINA Regional Medical Program        -7-

         Status of Projects not Funded

         Project Title and Number                                           Status

              - Breast Cancer - Mammography Screening                 Returned for Revision
         i@17 - Stroke Rehabilitation                                 Disapproved
         #19  -Nuclear Medicine Diagnostic Unit                       DisapprovF-,d
         #21  -Coronary Care Education and Screening                  Returned for Revision
                (resubmitted as #37 in this application)
         #22  -Demonstration, Services and Education                  Approved - Unfunded
         #23  -Core for Coronary Care Unit                            Approved - Unfunded
         #24  -Planned Discharge and Progressive Care                 Disapproved
         #27  -Nuclear Medicine Diagnostic Clinic                     Withdrawn
         #28  -Coronary Care Unit Telemetry                           Disapproved
         #29  -Care of Children with Heart Disease                    Approved - Unfunded
         #30  -Improvement of Nursing Services                        Returned for Revision
         #32  -Chronic Respiratory Disease Training                   Returned for Revision
                (resubmitted As #36 in this application)
         #33  -Coronary Care Unit - Beaufort                          Disapproved
         #34  -Education of Head and Neck Cancer                      Returned for Revision









                                                                      DRMP/GRB
                                                                      5/22/70




                                                                          (A P):j--,?il,ececl Cop-imuni.cati.on'



                                      SU@Z.IARY OF REVIEW AND CO,.ICLITSIOTT OF
                                            JUNE 1970 REVIL@'@,@' COL\@PIIITTI,,E


                                   SOUTH CAROLINA REGYOIQAL MEDIC-A-L PROGRAM
                                                  RM 00035  7/70.1


                              FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL



              General:  The Committee did not recommend supplemental funding for the
                           South Carolina @IP for the projects for which funding is re-
              quested in this application.   Of the two projects in this application
              which were previously returned for revision, #36 - Chronic Respiratory
              Disease Training was recommended for a site visit and lk37 - CoronarN,
              Care   Risk   Factor   Education   and   Screening   was   recommended   for    Non-Approval
              1, no l@TS funding recommended.  Revision is required for the third
              project Yk35 - Comprehensive Coronary Care Program for Comm                 t    l@o@    als
              in the Central Subr

              Project lk35 - Comprehensive Coronary Care Program for Community                      t--als.

              LrLti@e:   Committee concurred with the observations and recommendations
                        .  of  the  Ad  Hoc   Cardiovascular   Study   Panel   that   this   project   has
              not   been   adequately   planned.   Although   the   objectives   are    clearly    stated,
              the  criteria   for   eligibility   of   participating   hospitals   may   not   insure   that
              areas with the greatest need will receive appropriate consideration.  Although
              a   comprehensive   chronology   is   presented,   the   procedures   described   leaNie   many
              unanswered  questions  which  relate  directly   to   the   success   or   fail-ure   of   the
              project.  The  time  requirements   for   trai.ning   of   coronary   care   nurses   are   not
              spelled   out.   Even   though   it   is   generally   accepted   that   the   effectiveness
              of  acute   coronary   care   will   improve       qttal.ity  training,@th4-s.   aspect   is
              iic)@, speL.'L(,Ci f)ut in the  application.  It is doubtful the nursing stal'l'
              described  can  give  adequate   coverage   to   the   system   proposed   either   at   the
              University  or  in  the  small  hospitals.  Thc-.   ratio   of   staff   nurses   to   patients
              raises questions as to patient care in special units and to patients on
              general  medical  services.  Although  tlc@  budget   appears   adequate,   ti-ic,,   breal,--
              clown  for  tr@ii-ning  is  unclear  and  the   oscilloscope   display   equipment   to   be
              purchased should be more fully described and justified.   Evaluation procedures
              which are briefly described do not spe6'ify how morbidity and mortality trends
              will be evaluated and baseline data for comparison is not mentioned.

              Committee concluded a(3 did the Study Panel that the project should be returned
              for revision and i,esubnilssioii to:       give  consideration  to  the  develop,,,-ic-nt   of
              other  areas  besides  Charleston   and   'pla7i   linlrages,   desi('n   more   appropriate
              in-service nurse training procrams with educational objectives clearly defined,
              and develop with the proposed curricultiii for CCU training in evaluation
              mechanism designed to meet objectives.
                                                  i

              Recoi-nmendation.,  @ion--Approval 11      Return for Revision.




            SOIJTII CAROLINA Regional                -2-             RM 00035  7/70.1
              T4.p.dical Program


            Project i@36 - Comprehensive R@i atoky Disease TraiTiiiip, Pro3zrim.
            Critique: The Committee agreed with  the  Continuing  Educat4-ori  and  Training
                        Panel's conclusion: a  -site visit is needed  to  gather  additional
            information before a recommendation c.,-i,, be made.  The RMP appears to be
            attempting to establish a  central  patieni"care  facility  with  a  continuing
            education component added as an adjunct.  The possibility of the V.A. Hospital
            or the University Hospital serving as  an  alternate  center  has  apparently  not
            been considered.  The overall goals are broadly stated; no behavioral goals
            are set for the educational component.

            A   statewide need is clearly presented  and well documented in  relation  to  the
            patient disease and current manpower  situation.  The  desire  seems  to  be  to
            establish respiratory centers in all    hospitals, where it might be more
            appropriate to get statewide agreement for subregional centers.  The budget
            is large, calling for extensive  staff.  In  the  third  year,  computer  hardware
            is requested. The time  frame  proposed  seems  too  short  when  consideration
            is made of the time needed to train the faculty  and  to  establish  the  labora.-
            tory. The time allocated for  staff  for  education  and  service  is  unclear,
            yet the tutorial approach to training would be time consuming.  The resources
            of the Region have not only beenidentified,their interest has been engaged;
            but the proposal does not  include  information  concerning  their  commitment  to
            supporting the training effort now or in the future.  In fact, it is not
            clear whether the hospitals are willing, or able, to establish the laboratories
            and treatment centers for which the trainees are being trained.

            Recommendation:  No action taken - sitevisit needed for additional information
                              and clarification of above questions.

            Project Y,@37 7 Coronary Risk Factor Education and  creeping.

                        The Committee  considered the questions raised by   the Ad Hoc
                        Cardiovascular Panel concerning this  project,  but  in  line  with
            their thinking on a simil-ar proposal frct-a the Bi-State P@IP, concluded  that
            the Region should not be encouraged to revise the proposal.  The Region
            should be advised that the  project  was  inappropriate  for  RMP  funding.  The
            Committee is concerned about a  Region'@  devoting  its  resources  to  planning
            further an activity for  which  the  ultimate  effectiveness  is  uncertain.  This
            project, for exarr@ple, is addressed only to the first phases which are necessary
            without any attention given to follow-up measures.  Volunteers are envisioned
            as an integral part of the program, yet no documentation is presented concern-
            ing theit ability to perform their roles.  The screening procedures and follow-
            up seem inadequate for the ob   ectivos without proper involvement of the patients,
            physicians on whom so  much  would  depend.  Professional  supervision  of  the
            activity is not adequately documented; it is  not  clear,  for  example,  if  a
            knowledgeable cardiologist with interest  in  risk  factors,  a  nutritionist,  or
            a health educator       be involved. M@iiiy.aspects of the budget  -  the  treicl-
            mill, el.cctrocardi-oiiiilyz.er, travel, are not sufficiently justified.




                SOIJTII Gl@ROI-,Il,','A                            -3                         00035   7/70.1
                  Medical        Program


                III SI-iort,  the CortifriitLee  felt tliit the RegioiA should be advised not to
                devote time to revisiiia         this      proposal.

                Rc,cc)iT@i-nend,-.tioi): Non-Approval- I      No PJTS Fui:idin.c@, Recoi,.aiieiicied.


                SLTNi4AI@Y OF RECO@',24E,\'Dk@'IONS

                r@ject    Title    and     #     --RecolflTqendati.ons      01        02     03       Total

                #35     Comprelierisive          Non-Approval       11      -0-      -0-     -0-         -0-
                        Coronary       Care      Return   for    Re-
                        Pr    ram    for         vision
                        Cornmun@
                        Hos,oitals

                #36     Comprehensive            No    Action    Taken      -0-      -0-     -0-        -O--
                        RespLra@o.y              Needs site visit
                        Disease       Train i@iq, for clarification
                                                 of cited concerns


                Yi37    Coronary       Risk      Non-Approval-     I        -0-      -0-     -0-       -O-.
                        Factor Education
                        and_Screenin,&


















                                                                                           DR@IP/CRB
                                                                                           7/15/70
















            0                                                              0                                                              0






                                  REGIONAL MEDICAL PROGRAMS SERVICE
                      SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                    (A Privileged Communication)
            SUSQUEHANNA VALLEY                                           RM 00059    7/70.1
            REGIONAL MEDICAL PROGRAM                                     June 1970 Review Committe,
            3806 Market Street
            P.O. Box #541
            Camp Hill, Pennsylvania  17011

            PROGRAM COORDINATOR:  Richard B. McKenzie

            Requested             Ist Year       2nd Year            3rd   Year      TOTAL
            Direct Costs          $296,650       $274,653              $191,736    $763,039
            Indirect Costs                               To Be Negotiated


            TOTAL                 $296,650       $274,653              $191,736    $763,039

            HISTORY:  This Region began its planning in June 1967 and became
                      operational on April  1,  1969.  Council  approved  eight
            operational projects for one year of support, one project for three years
            of support and core for nine months; the  periods  of  support  recommended
            were the requested ones.  The total current level of funding is $831,735;
            $239,125 for projects and $592,610 for core.  $143,941  of  the  funds  for
            projects is carryover.
            The grantee agency is the Pennsylvania  Medical  Society;  the  Coordinator
            was an executive assistant with the  Pennsylvania  Medical  Society  before
            assuming his present position.  The Coordinator reports both to the
            Regional Advisory Group and the Executive Director of the Pennsylvania
            Medical Society. Assisting the  Coordinator  and  the  Regional  Advisory
            Group in review and decision making are  categorical  Councils,  four  Area
            Committees, and a 20-member core staff.
            This Region has emphasized "grass-roots  development"  and  coronary  care.
            Of the 19 projects which the Region has submitted,  15  have  dealt  with
            some aspect of coronary care.  Many of these projects appeared to
            Committee and Council to be a disparate  group  of  primarily  equipment
            requests with little sense of their relation  to  the  Region's  overall
            plan for coronary care.
            Because the nature of the projects seemed  to  indicate  some  difficulty
            with regional planning, a site visit was held in February 1970 to
            assist the Region in better organization and  delineation  of  its  plans
            and organizational arrangements.  The site visitors reported that
            the Region has been attempting to strengthen the regional decision
            making by the establishment of Planning  and  Evaluation  Committees  and
            the restructuring of core staff and that these changes had not had
            sufficient time to affect  the  written  application.  Review  Committee
            and Council urged that while continuing to encourage grass roots



            SUSQUEHANNA VALLEY                      -2-                  KM UUUDY ///V.l
            Regional Medical Program
            involvement, the Region should devote more attention to developing a
            regional decision-making process which selects projects for submission
            on the basis of a plan derived from the Region's, rather than just
            individual community's needs. As evidence of efforts in this direction,
            the Region has introduced the projects in the present application with
            narrative relating to overall program planning and the role of each
            project in the context of the total program.
                                                                                  Requested
            Project #20 - Emphysema Program.  This project will attempt to        First Year
                        alleviate the emphysema problems by establishing a         $52,475
            specialized treatment center and applying a multidisciplinary approach
            to the u,.'3e of equipment and personnel.
            The treatment center will be established in the Community General
            Osteopathic Hospital in Harrisburg and will draw patients from primarily
            a six-county area in the southern part of the state.  Presently, there
            are only six such centers in the country; the proposed center will be
            patterned after the Moss Pulmonary Rehabilitation Unit in Philadelphia.
            Patients will be referred to the program by their physician.  The
            patient will receive historical, medical and psychological evaluation
            and then be placed in one of five classifications from no restriction
            of normal activities to restricted to the home.  The intent of treatment
            will be to progress the patient to less severe classifications.  The
            project states two new patients will be admitted to the treatment center
            every week, but it does not indicate how many patients the center can
            accommodate at one time.  As an inpatient for a least two weeks, each
            patient will undergo intensive treatment which may include medical,
            physical, inhalation or occupational therapy, and health education.
            Periodic evaluation and correlation of physiological and psychological
            findings will be made, with an assessment of each patient's response by
            the team which consists of the project director, psychiatrist, nurse,
            social worker, psychologist, physical therapist, occupational therapist,
            inhalation therapist and pulmonary function technicians.  When the
            patient has shown satisfactory progress, he will be prepared for
            discharge to the continuing outpatient program.  After discharge, each
            patient will be periodically reexamined and tested to determine a change
            in classification.  Data on this change will be correlated with the
            length and nature of treatments and evaluated.
            Physician and nurse education has been planned for.  Physicians will
            be invited to attend team conferences and will be sent copies of
            summaries and reports on his patients.  Nurses will also be invited
            to attend team conferences and will also be instructed in the general
            nursing care of emphysema patients, the use of mechanical devices and
            the principles of pulmonary rehabilitation.





            SUSQUEHANNA VALLEY                         -3-                RM 00059  7/70.1
            Regional Medical Program

            The budget requests $34,250 for personnel, $14,225  for  equipment,
            $3,000 i-@i supplies and $1,000 in publications.  The cost of
            inpatient care will be covered largely by private  insurance  and
            Medicare.  The hospital will accept any patient, regardless of
            ability to pay.  Outpatients not covered b@, Medicare will be
            offered a special package of 25 visits for $100.

            Second Year:  $49,000                           Third Year:  $49,575

                                                                                     Requested
            Project #21 - Enterost(ymal Therapy Training - Harrisburg Hosl')ital.    First Year
                          The Harrisburg Hospital and the  Harrisburg  Hospital       $18,883
            Medic al Education and Research Foundation, Inc., are seeking RMP support
            to develop and organize a program to train enterostomal  therapists.
            The Harrisburg Hospital has operated the training program on  a  pilot
            basis but will have to abandon it unless an outside source  of  funding
            can be found. Individuals who are  qualified  registered  nurses,
            licensed practical nurses or other acceptable allied  health  personnel
            will be trained to provide services, training and  instruction  to
            patients with a permanent or temporary gastrointestinal  or  urinary
            fistula, such as colostomy or ileostomy. The  trained  therapists  will
            also provide instruction and training to nursing and  physician  groups.

            Initial priority in selecting students will be given to training  at
            least one nurse from each hospital within the Region;  second  priority
            will be given to staff members of the Visiting  Nurse  Association.
            Twelve students will be trained each year in twelve  four-week  courses.
            One student is trained per course. The small discussion  group  is  used
            in which the trainee receives individual instruction from two therapists,
            a physician a hospital and a  community  resource  individual.  Trainees
            are also required to assist the enterostomal therapists in  the  stoma
            clinic and observe an ostomy operation.  Each trainee will be evaluated
            by each instructor and by a review of 50 case summaries submitted by the
            trainee within six months after completing the program, as well  as  by
            reports from the graduate therapist and his supervisor.

            The $18,883 request for the first year includes funds  for  personnel,
            supplies, travel, and student expenses.

            Second Year:  $19,814                           Third Year:  $20,695

                                                                                      Requested
            Project #22 - Physician and Paramedical  Rehabilitation  Training         First Yea@.
                          Program, Williamsport Hospital.  This  project  requests     $35,837
            funds to: 1) teach physicians the latest knowledge  in  diagnosis,
            rehabilitation treatment and psychology and use of  special  equipment;
            2) train paramedical personnel in rehabilitation therapy;  3)  deliver
            new and improved physical medical care to heart, stroke, cancer  and
            neurologically handicapped patients throughout eleven  counties  in
            the northern part of the state; and 4) aid in restoration  of  the
            motor-body functions of patients when they are first  disabled  in
            order to provide prophylaxis against more serious  and  permanent
            disabilities.





          SUSQUEHANNA VALLEY                      -4-                  RM  00059  7/70.1
          Regional Medical Program
          The sponsoring hospital, Williamsport Hospital, has  recently
          completed an 80-bed rehabilitation center which is the only such
          center in the Northcentral Pennsylvania.area.  A questionnaire
          sent to hospitals in the 15-county area indicated that 16 of 18
          hospitals which replied would be interested in training for
          paramedical personnel and physicians in rehabilitation.
          On that basis two sets of courses have been planned.  The first
          is a five-day course for physicians held twice a year for two
          years.  Each course, including lectures by various specialists,
          demonstration of and participation in therapy, diagnosis  and
          treatment of stroke patients, and conferences with  ancillary
          medical personnel, will be limited to five physicians.  The
          second group of courses is a ten-day paramedical training program,
          limited to 25 students each.  It will attempt to give nurses,
          physical therapy aides and orderlies the techniques and execution
          of rehabilitation therapies. A curriculum  is  included.  The
          program will be reviewed to determine its value to the,  participants,
          rather than attempting to measure the benefit to  pati6nts  throughout
          the 11-county area. -
          Second Year:  $34,186                        Third Year:  None
                                                                                  Requested
          Project #23      rid             ystem Pilot Project, American Cancer  Fi st Yeat
                     7
                       Society, Pennsylvania Division.  The  objective  of  this    $4,973
          one-year proposal is to evaluate two types of cartridge viewing
          systems - The Fairchild Super 8mm and the Technicolor Model 1000  B  -
          in order to develop criteria and appraise all aspects of cartridge
          viewing systems.  Five Fairchild projectors will be placed in five
          hospitals and five Technicolor projectors will be placed in five
          different hospitals.  After three months usage, the ten hospitals
          will exchange projectors.  After another three months usage, different
          hospitals will be selected.  In two years, 20 hospitals will be involved
          in the comparative study.  The American Cancer Society will administer
          the project by providing a variety of cartridge films and accompanying
          material, servicing the systems and tabulating  the  evaluation  data.
          The schedule for the projector will be sent out in advance  to  enable
          the hospital to schedule films and involve the projector in their
          nursing and continuirgmedical education program.  The  projectors  are
          also available for patient rehabilitation and  public  education.  The
          projectors may also be put in the nurses and physicians'lounges where
          individuals may review a film previously presented or  one  that  they
          could not attend.  An evaluation will be made in each hospital at the
          end of each of the four three-months  periods.  The  intervening  time
          between assignments should allow for planning a more complete  use  of
          the projector. There will be a single evaluation made  by  a  hospital
          each time a projector is used, a comparative evaluation of  the  first
          and second usage of both projectors and a  composite  evaluation  made
          each year for the twenty hospitals involved in  the  program.





            SUSQUEHANNA VALLEY                       -5-                 RM 00059  7/70.1
            Regional Medical Program

            A preliminary study was conducted at one hospital in  Gettysburg
            where 104 viewings took place in a two-month period.  The  proposers
            stated that they felt the use of the projector was important  in
            stimulating the development of this hospital's first  continuing
            education program.


            Second Year:  None


                                                                                      Requeste(
            Project #24 - Nurses Training Program for Coronary Care Units             First Ye4
                          Harrisburg Hospital.  At the present time the entire          $46,640
            Susquehanna Valley Region has only one nursesi coronary care  training
            program - the four-week program at the Geisinger Medical  Center.  The
            Geisinger Program has started its second year of operation under  RMP
            funding and has more requests than it can handle in the Northeastern and
            Northern Areas alone. The project at Harrisburg Hospital  would  serve
            hospitals in the Southern Areas who estimate that they will need  285
            nurses for coronary care units in the next three years.

            This project was reviewed by Council in December 1969 and returned
            for revision because the proposal had not documented the need for  a
            twelve-week course and the curriculum was not adequately  described.

            The objective of this revised proposal is to provide hospitals in
            the Southern Area with trained nurses who are capable of working
            independently in or supervising a coronary care unit.  The Region
            feels that the presence of both four and twelve-week courses  within
            the Region would offer an opportunity for a comparative  evaluation.
            Ten to fifteen nurses will receive didactic lectures, participate  in
            discussions and clinical experience in a twelve-week training  program,
            utilizing the physicians and nurses of the Harrisburg Hospital.  Three
            courses will be held per year. The course is designed  for  graduate
            nurses with at least six months experience in general duty.  Both  a
            course outline and the daily training schedule are included.  Evaluation
            will consist of a comparison of mortality statistics of coronary
            patients before and after the establishment of a unit and a  subjective
            evaluation of the graduate by his coronary care unit director.

            The hospital will provide room and board for the students during  the
            course.  Funds are requested from RMP for reimbursement of the
            instructors, supplies and equipment and dietary costs.

            Second Year:  $47,960                         Third Year:  $49,918

                                                                                     Requested
            Project #25 - Nurses' Training Program for Coronary Care  Units,         First Yeai
                          Altoona Hospital. This project would provide  a  four-      $55,643
            week coronary care course for nurses in the Appalachian-Highland  area.
            December Council returned for revision an earlier version of this
            project also, because they could not ascertain this project's part  in
            the Region's overall plan for coronary care units. This  hospital,  the
            reviewers thought should be encouraged to assume more responsibility for




         SUSQUEHANNA VALLEY                     -6-               RM  00059  7/70.1
         Regional Medical Program
         regionalization, such as offering assistance to nurses in their
         sponsoring hospital, after the course is completed.  Salaries and
         equipment costs in the $55,643 first-year request seemed high.
         This hospital has already trained 25 nurses and is requesting RMP
         support to train a total of 96 nurses (twelve trainees per class
         and four classes per year) for hospitals in a four-county area.
         The program is planned to train the nurses in the use of monitoring
         equipment, electronic defibrillating, cardioversion, electrocardio-
         graphic interpretation and specialized nursing techniques.  T e
         course is divided into 40 hours of lectures, 30 hours of lab and 80
         hours'of clinical instruction.  The nurse must be a graduate RN with
         a current state license and recommended by the employing institution.
         Evaluation will stress relevant curriculum content, teaching methods
         and aids, participant feedback and follow-up.
         Af ter two years the program will be subsidized by the  Altoona  Hospital
         and supported by tuition fees.
         S6cond Year:  $55,643                            Third Year:  None
                                                                                  Requested
         Project #26 - Cardiopulmonary and CVA Transport Vehicle - York H6sDital. First Ye-:-
                      The December 1969 Council reviewed this project and          $82,20C@@@@,@I
         recommended returning it for revision.  The reviewers had difficulty
         in assessing the need for the project and the adequacy of trained  man-
         power to staff the mobile coronary care transport vehicle. The  size  of
         the area and characteristics of the population were not  described.  The
         application did not document the statements of high rates of  complica-
         tions associated with hospitalized myocardial infarction patients  which
         occur during transport. Although the vehicle would be staffed  by  both
         a physician and experienced nurses during the week, staffing of the vehicle
         on nights and weekends was unspecified. Also a  more  definitive  protocol
         for evaluation than the collection of anecdotal records and routine
         mortality data would be necessary for proper determination of the
         effectiveness of the ambulance.
         The project will serve the greater York County area which includes
         275,000 people divided approximately equally into urban and rural.
         This pilot project intends to provide a demonstration of the  effective-
         ness of a cardiopulmonary transporter in reducing morbidity  and  mortali-
         ty from myocardial infarction and stroke prior to entry into the hospital
         in the York area. The proposers hope to evaluate the  effect  of  bringing
         a physician, trained nurse and necessary monitoring and resuscitation
         equipment into contact with patients sooner than is possible under
         present conditions.





          SUSQUEHANNA VALLEY                     -7-                   RM 00059  7/70.1
          Regional Medical Program

          The basic cardiopulmonary transport vehicle would be a step  van
          truck equipped with a self-contained resuscitation unit, a  Bird
          pressure volume respirator and connected by two-way radio  for
          initial and continuing voice contact with the hospital  emergency
          room and coronary care unit. The vehicle would  be  dispatched
          either by a direct call to the medical resident in the  coronary
          care unit of the York Hospital or through the existing York  Police
          radio network in conjunction with a physician, industrial  health
          nurse, etc. The van will be staffed normally by a  driver,  an
          orderly, a CCU nurse.and a medical resident assigned to the  CCU.
          On off hours on evenings and weekends it will be staffed by one  of
          two medical residents on duty supported by the interns on cardiology.
          Specially trained nurses will also serve as staff on nights  and
          weekends. The hospital's Educational and Care Evaluation  Unit  will
          supervise and standardize evaluation mechanisms. The  criteria  will
          include a detailed review of incidents, epidemiology,  recovery,
          compared to before and after establishment of the mobile  unit
          function. Evaluation of mortality statistics, as well  as  anecdotal
          and objective material, has been planned for.

          For the initial part of the study, no fees will be charged  in
          order to stimulate use of the service. After the program  has  been
          established, the program will continue on a fee-for-service  basis.
          The first-year budget consists of $52,000 for personnel,  $10,500
          f6r consultant services, $17,200 for equipment and $2,500  for
          supplies.
          Second Year:  $68,050                          Third  Year:  $71,548




















                                                                 IMPS/GRB/5/14/70







                                                                            SUSOUEHANNA      RMP
                                                                            RM   00059    7/70.1





            STAFF OBSERVATIONS

                                     Su-,nmary of Review Actions and Funding
                                                                                               Status and
            Project                                                                            Current         ort
            #1   -   Evangelical   Community   Hospital   CCU    (02    year)                     $    4,264
            #2   -   Sunbury   Community   Hospital   CCU   (02   year)                                2,231
            #3  -  Shamokin   State   General   Hospital.   CCU   (02   year)                          4,160

            #4 - A.C. Millikan Hospital CCU (02 year)                                                  3,900
            #6R- Coronary Care Unit Nurses Training Program,                                        26,978
                     Geisingeic Medical Center (02 year)
            #7 - Stroke Care Unit, Mercy Hospital, Altoona (02 year)                                55,339

            #8 - Home Health Care Project (02 year)                                                 15,952
            #9   -Regional Medical Information Service (02 year)                                    55,580
            i@10- Training   of   Personnel    for    Coronary    Care,                             Disapproved
                  Harrisburg Hospital
            #].I- Nurses' Coronary Care Training Program,             Altoona Hospital              Disapproved
            #12-  Cardiopulmonary and CVA Transport, York             Hospital                      Disapproved
            #13-  Travenal Resuscitation Cart, Pottsville             Hospital and                  Disapproved
                     Warne Clinic
            i@14- Emergency Coronary Care Program, Coaldale State                                   Disapproved
                     General Hospital
            Y@15- Emergency Coronary Care Program, Locust Mountain                                  Disapproved
                     State General Hospital
            #16-  Radiological Health Training Program, Geisinger                                   17,993
                     Medical Center (01 year)

            #17-  ColumbiaMoi--itour Home Health Services, Inc. (01 year)                           15,900

                                                                       TOTAL                        $202,297


            I/Initiated with funds from the $5 milli-on.


                                                                                                           5/12/70








                                                               A  Privileged   Communication



                               SUMMARY OF REVIEW AND CONCLUSION OF
                                    JUNE 1970 REVIEW COMMITTEE

                           SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM
                                         RM 00059  7/70.1

                        FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL


              General:  The Susquehanna Valley  RNP  submitted  a  supplemental  application
                         for seven projects requesting $763,039  for  a  three-year  program
              period.  The Committee concluded that the  'application  should  be  supported
              as follows:  $101,083 the first year to support Projects #21 and-#26,
              $87,864 the second year and $92,243 the third  year  to  support  the  same.
              Projects #20, #22, #23, #24 and #25 were disapproved.

              Reviewers continue to see a lack of overall regional planning in the
              written application, but recalled that the February site visit team report-
              ed that progress is being slowly made.  Three projects which had been
              revised and.four new projects were reviewed.  The technical panels reviewed
              all but one of the projects and were  highly  critical;  with  one  exception,
              they found all of  them  technically  unfeasible.  The  Committee  regretted
              that their one member familiar with  the  Region's  problems  and  priorities
              was unable to attend the meeting, and in the  absence  of  this  member,  felt
              compelled to accept  the  panels'  technical  assessment.  Committee,  however,
              was concerned about the effect of returning  two  projects  for  revision  a
              second time.



              Project #20 - Emphysema Program
              Critique: Reviewers appreciate the need for  such  a  facility  since  no  such
                          facility exists for comprehensive  treatment  of  emphysema  and
              bronchitis in Central Pennsylvania.  The  Ad  Hoc  Cardiovascular  Study  Pane
              and Committee's principal concern relates to relationships between the
              Osteopathic Hospital and other  agencies,  institutions  and  physicians  who
              would refer patients. Although  surrounding  hospitals  have  agreed  to  refer
              patients and health agencies have endorsed the project, reviewers were
              concerned about the future,of the project without commitment from the
              medical profession.

              With regard to the project description,  the  Panel  believed  that  greater
              emphasis should be given to early detection,  more  details  should  be  pro-
              vided on patient selection and consultation  should  be  sought  in  evaluation
              to settle questions as to how data will be  derived  for  comparison  of  re-
              sults of the hospital team approach and  that  of  the  private  physicians.
              Portions of the psychosocial work-up might be considered research with
              little likelihood of obtaining definite conclusions.






            Susquehanna Valley RMP            2               Rm 00059  7/70.1

            While the Panel deferred their recommendation pending a satisfactory
            site visit rpport, Committee concluded that since the bulk of the costs
            would support staffing of the;hospital, the project should be disapproved.
            Recommendation:  Non-Approval. I (no RMP funding recommended).

            Project #21 - Enterostomal Therapy Trainin@,,    isbukg Hospital
                       This project appears to be a much needed resource for the
                       entire Region, since it is the only training program of its
            kind in the Region.  The objectives are clearly stated and the educational
            design appears sound.  Training is individual with a great deal of time
            bein- spent on bedside instruction and practice.  Evaluation of student
            performance appears sound.
            Committee recommended approval of this ongoing activity, which apparently
            will not be able to continue without RMP assistance.
            Recommendation:  Approval in the amount and for the time requested.
                        01                       02                       03
                     $18,883                  $19 8T4-                 $20,695

            Project #22 - Physician and Paramedical Rehabilit4tion Training Program,
                          Williamsport Hospital
                       The Continuing Education and Tr,.iining Panel was very critical
                       of this proposal.  They found fault with the educational design,
            evaluation and the budget.  For example, they found little evidence of
            the manner in which reinforcement would be provided in physician training.
            The depth of the reinforcing clinical experience for paramedical personnel
            could not be assessed since the distribution of learners in relation to
            numbers of patients was not stipulated.  The evaluation, focused primarily
            on rates of participation, subjective responses to questions concerning
            interest and a questionnaire checkoff, would not indicate any change in
            behavior or measure outcome.  The budget ($600 per student for five to
            ten days of instruction) see-qied excessive.
            Committee acknowledged these comments and added that the aims of this
            project have already been demonstrated at many rehabilitation centers
            around the country.  Consequently, although the need exists, the project
            in its present form is disapproved.
            Recommendation:  Non-Approval I (no RMP funds recommended).






               Susquehanna Valley RMP         - 3 -             RM 00059  7/70.1

               Project #23 - Cartridge_Viewing System Pilot Project, American Cancer
                             Society, PennsNlvania Division
               CritLque: The Continuing Education and Training  Panel  and  Review  Com-
                          mittee agreed that this proposal is basically  a  request  for
               purchasing equipment, rather than a valid evaluation of  equipment  or  of
               educational outcomes because of its use.  Technical assessment should be
               performed by the company who develops the equipment and not RMP.
               There is little effort to relate this project to educational objectives;
               assessment of the number of viewings for a novel media in such  a  a  ort
               time span is really no evaluation.
               Recommendation:  Non-Approvai I (no RNP funds recommended).


               Project #24   Nurses Training Program for Coronary  Care  Units,  Harrisburg
                             Hospital
               Critique:  Although this proposal had been returned and revised once
                          before, it was again found unaporovable in  its  present  form
               and returned for revision.  Previous criticism related to the lack of
               documentation of the need for a twelve-week course and to  the  need  for
               a more adequately described curriculum.
               Committee noted the Ad Hoc Cardiovascular Study  Panel's  comments,  which
               indicated they still were not convinced that the  twelve-week  course  would
               adequately produce supervisory nurses. The emphasis  of  the  course  seemed
               to be disease-oriented with minimal indication of the explicit supervisory
               skills and judgments needed, and a large portion of the  last  five  weeks
               is devoted to nursing duty, including evening and night shifts.  Evening
               and night tours of duty are strongly questioned by  the  National  League
               of Nursing as ideal learning situations. The  Panel  stated  the  curriculum
               should include an indication of how specific objectives  will  be  attained,
               nurse education consultation and input, and an  evaluation  scheme  which
               would relate to conduct during the course and after return to  .the  nurse's
               home  hospital.
               Because the project has apparently not satisfactorily  answered  its  pre-
               vious criticisms, Committee believed that a revision was  needed  to  review
               it. Committee believed that what is needed is a  better  model  for  such
               a training program and consultation from leaders in nursing education in
               the state.

               Recommendation:  Non-Approval II (revision required).


               Project #25 - Nurses' Training Program for Coronary  Care  Units,  Altoona
                             Hospital
               Critique:  This is a request for the traditional four-week coronary care





          Susquehanna Valley RNP             4 -           RM 00059  7/70.1

          nurse training program.  The Committee noted that this project would
          serve. the western area of the Region, and t.@at the only other coronary.
          care training program was at the Geisinger Medical Center in the eastern
          section of the Region.  Although the project spoke to the comments of
          previous reviewers, the Ad Hoc Cardiovascular Study Panel-had additional
          criticisms:   (1) the objectives are not stated in terms of education of
          the learners; (2) other than a general reference to follow-up, the pro-
          posal does not speak to any evaluation of the student's retention of
          knowledge or employment status after training and (3) evidence of
          nursing input into the curriculum is missing.  In light of these comments
          and the absence of the Committee member who could provide input on the
          background of the Region s planning in this area, Committee accepted the
          Panel's recommendation  of  disapproval.
          Recommendation:    Non-Approval I (no RMP funding recommended).

          Project #26  -  Cardiopulmonary And CVA Transport Vehicle, York Hospital
                     Committee   believed this revised project had, for the most  part,
                     met  the  criticisms of earlier reviewers, which included deter-
          mination of need,  adequacy  of mastpower to staff the vehicle, and evalua-
          tion protocol.  The  locale  of this project in York, which is also  involved
          in the Maryland RMP,  was  noted.
          The Ad Hoc Cardiovascular Panel's recommendation of disapproval was based
          on an erroneous belief that RNP policy forbade further expenditure of RMP
          funds on CCU ambulances until evaluation of present ambulance projects
          is completed.  The Panel's suggestions that medical society endorsement
          be sought and that evaluation be further strengthened were adopted by
          Committee.
          .Recommendation:  Approval I with the conditions that evaluation be
                            strengthened and medical society endorsement  be  obtained.
                        01                       02                       03
                   $82,200                   $68,050                   $71,548
          Conclusion:  A total of $281,190 was recommended for Projects #21 and #26
                        for a  three-year  period.


                                                      01             02               03
          Project  #20  -Emphysema Program       Non-Approval I (no RMP funds  econmended)
          Project  #21  -Enterostomal Therapy       $18,883      $19,814          $20,695
                         Training
          Project  #22  -Physician and Para-     Non-Approval I (no RMP funds recommended)
                         medical Rehabilitation
                         Training   Program






              Susquehanna Valley RMP            5              RM 00059  7/70.1

              Project #23 - Cartridge Viewing      Non-Approval I (no RMP funds recommended)
                            System Pilot Project
              Project #24 - Nurses Training        Non-Appkoval II (revision required)
                            Program for CCUS,
                            Harrisburg
              Project #25 - Nurses Training        Non-Approval I (no RMP funds recommended)
                            Program for CCUS,
                            Altoona
              Project #26 - CPR and CVA Transport    82,200          68,050          71,548
                            Vehicle, York

                            TOTAL                  $101,083         $87,864         $92,243




































                                                                        DRMP/GRB  7/13/70

















          I 0                                                                                                                             0









                            DIVISION OF REGIONAL MEDICAL PROGRAMS
                 SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                               (A Privileged Communication)

            TEXAS REGIONAL MEDICAL PROGRAM                           RM  00007  7/70.1
            P. 0. Box " Q"                                           June 1970 Review Committee
            University Station
            2608 Whitis Street
            Austin, Texas  78712

            Program Coordinator:  Charles B. McCall, M.D.

            Requested
            Program
            Period                lat  Year     2nd  Year     3rd  Year    TOTAL

            Direct Costs:          $610,363      $351,414      $295,655     $1,257,432
            Indirect Costs:         161,951       115,998        98,090        376,039


               Total               $772,314      $467,412      $393,745     $1,633,471

            History:  Texas received an 01 planning award    ($969,541) on July  1,  1966
                      and its 02 award ($1,039,295 dco) on July 1, 1967.

            A site visit was conducted in June  1968 to determine the Region's
            readiness for operational status and  to  review  the  proposed  continuation
            of planning activities into the  operational  phase  of  TRMP's  development.
            of major concern to the reviewers was the apparent lack of central
            direction and coordination of the program.  This was illustrated by the
            uneven progress made in the development  of  the  nine  subregional  planning
            units and by the fact that operational proposals  appeared  to  be  "based
            on institutional interests and strengths with very little regard for
            community needs and goals - either regionwide or local - and only a few
            show evidence of true cooperative arrangments  or  even  unilateral  peri-
            pheral involvement."  The site team also observed that the Regional
            Advisory Group, though under strong leadership, had  not  been  active  in
            the identification of program goals and the development of program plans.
            The RAG was also weak in its representation of minority groups, consumers,
            allied health professions, and the practicing community.

            With these considerations in mind, the Council recommended a one-year
            approval of the Texas operational  application,  including  the  continued
            planning support, with future funding contingent upon demonstrated
            improvement in the areas mentioned by the reviewers.  Accordingly, a
            one year operational award was issued on July 1, 1968 in the amount
            of $1,615,000 (dco), these funds to be divided evenly between operational
            and planning activities.  This combined package included fourteen






              Texas Regional Medical Program         -2-            ItM  00007   7/70.1

              operational projects slid a number of planning efforts which included
              core suppor-t and support for the nine  institutional  planning  units.

              A subsequent visit was held in April 1969  to  judge  the  progress  made
              in fulfilling the conditions laid down the  year  before  as  necessary
              for further funding, that is,  strengthening  central  administration  and
              expanding the RAG.  The reviewers were well satisfied that these require-
              ments were being met; a new coordinator had been app6  inted and had
              presented his plans for tightening Up  the  organization,  and  the.RAG
              included nine new interested groups that had not been represented
              earlier.

              The Region received its 02 continuation award ($2,220,891 dco) on
              October 1, 1969.  This award included support for core and eight
              planning bases, ten project renewals, and eleven new projects.

              Present Application: This  application  requests  renewed  support  for
                                     three activities and  supplemental  support  for
              two new projects.  Direct costs only are noted below.

                                                                             Requested
                                                                             First  Year
              Project #8(R) - State-Wide Cancer Registry System              $184,396
                              This is a renewal application of a  project  now  in  the
              second year of development of a  computerized  regional  cancer  registry
              system. The 01 year award was $38,000 d.c.  and  02  year  funding  was
              $80,000.

              This project grew out of the recommendations  of  a  committee  organized
              during the early planning stages of TRMP to look  into  improving  the  care
              given to cancer patients in the state.  This group included representatives
              of the University of Texas, Baylor College of Medicine, the Cancer Committee
              of the state medical society, the state division  of  the  American  Cancer
              Society, and the State Department of  Health.  After  evaluating  the  need
              for a more comprehensive medical information system  for  cancer,  it  was
              proposed that a central registry be established and  that  it  operated  out
              of the University of Texas School of Public Health.  It  was  felt  that  by
              utilizing this resource, additional  data  process,  consultation  data
              analysis and statistical support could be provided to existing registries.
              The June 1968 operational site visit did  not  recommend  any  support  for
              this project in the 01 year and encouraged the Region to resubmit it
              after some further development.  TRMP, however, exercised its prerogative
              to fund the project on the basis of its  importance  to  the  Region.  The
              April 1969 site team felt that sufficient  progress  had  been  made  and
              recommended continued support in the 02 year.
              The goal of the renewal proposal is to  integrate  this  central  computer-
              ized cancer information system for the State to help  improve  the  care  of
              cancer patients by assisting physicians in their follow-up and treatment.






             Texas Regional- Medica' Ilropran@i               RM 00007
                                   L    -                               7/70.1


             This will be accomplished by establishing a  central  bank  of  cancer  data
             and by extending this service to  a  larger  proportion  of  the  population
             within the Region.  Such a cancer information system -will promote research
             into the epidemiology and othe-r population  dynamics  relative  to  cancer.
             Once this system has been developed, it will  be  tested  for  its  applica-
             bility to other areas such as heart  and  stroke  and  may  be  expanded  to
             include them,

             A staff, consisting of a M.1). coordinator, a Ph.D.  demographer,  a  Pli.D.
             stati.stician-information scientist, a  secretary,  keypunch  operator,  and
             two clerk-typists, has been assembled.  Information  has  been  obtained  by
             questionnaire on the nature and scope of  existing  registries  both  within
             and outside the State of Texas.  Arrangements  have  been  made  to  utilize
             the Texas State Department of Health  Spectra  70/45  Computer,  which  will
             become operational during April 1970. San Antonio will  be  the  site  of  a
             pilot project to test the  reporting  procedures  and  computer  system,  as
             well as to serve as a training unit:.  Cancer morbidity data for 1944-1966
             for San Antonio are currently being placed  on  magnetic  tape  and  edited.
             Projected future activities include:  (1)  development  of  a  standard  set
             of reporting forms and data codes, (2) the determination of systems design
             and Computer program to al.low flexible data  handling  and  analysis,  easy
             up-dating and fast retrieval, and (3) a cl.ear  definition  of  channels  of
             information flow.
             Second Year:    $1.32,251                     Third Year-            $97,542

                                                                        Requested
             Project #14(R) - Stroke Demonstration @@raLn_for           First Year
                              Progressive Patient Care                  $196,244
                              This is a renewal application to   continue the development
             of the Stroke Demonstration Program by the University of Texas (Southwestern)
             Medical School and  Presbyterian  Hospital,both  in  Dallas.  This  proposal
             was originally funded ($240,499 dco) on April 1, 1968  as  a  one-year  ear-
             marked supplement to the pi.anning grant. Due to the  number  of  delays  in
             the construction of the strol(e unit itself, the  program  period  has  been
             extended to September 30,  1970  without  additional  funds.
             Construction of the special 22-bed stroke unit  was  completed  the  end  of
             November 1969.  A multi-disciplinary team consisting of neurology,
             nursing, and rehabilitation personnel has begun to provide intensive
             acute care, early rehabilitation, and continuing  patient  care  within  the
             framework of a demonstration project  which  also  provides  for  continuing
             education of physicians, registered  nurses,  and  allied  health  personnel
             in the North Texas area.  Personnel  from  both  Presbyterian  Hospital  and
             the faculty of The University of Texas (Southwestern) Medical School
             make LIP the project staff.





             Texas Regional Medical Program       -4-       Rm 00007    7/70.1

             This program is also directed at both the  early  diagnosis  of  stroke  (or
             impending stroke) and the training  of  physicians,  nurses,  and  allied
             health personnel in comprehensive progressive care.  The regional applica-
             tion of this program will be further implemented during the present fiscal
             year as the stroke unit becomes fully operational.  Related or coordinated
             satellite units in surrounding community hospitals are planned.
             Second Year:      $164,344                 Third Year:       $142,844

                                                                                   Requested
             Project #15(R) -  Area-Wide Total Respiratory Care.  This   is a      First Year
                               request for renewal support for a third   year  for   $80,000
             the .@!Area-Wide Total Respiratory Care" project, now  in  operation
             at Baylor College of Medicine. The 01  year  was  funded  at  $174,388
             d.c. and the 02 year at $242,915.  Both the current program and
             this renewal application address the  need  for  organized  planning  and
             increased services on a broad scale in  the  field  of  chronic  obstruc-
             tive pulmonary disease.  The  twelve  counties  surrounding  Houston
             represent the area of involvement for  community  programs  of  early
             detection, application of preventive measures,  and  both  public  and
             professional education.  Emphasis will be placed on an active
             program of continuing education for  the  community  physicians  and
             nurses in the area, utilizing  the  respiratory  disease  screening  pro-
             gram, teaching clinics, and bedside  instruction  in  the  medical  center.
             A pulmonary rehabilitation program  will  be  undertaken  in  conjunction
             with the RMP "Rehabilitation  Management  -  Coordinated  Community  Action
             Program" at St. Elizabeth's Hospital in Houston.
             Through the efforts of this program, there has  been  an  increase  in
             activity in all of the  Baylor  College  of  Medicine-affiliated  hospitals
             (Veterans Administration, Methodist  Hospital,  St.  Luke's  Episcopal
             Hospital, Ben Taub General Hospital and  Jefferson  Davis  Hospital  of  the
             Harris County Hospital District)  relative  to  respiratory  disease
             screening, patient services and  professional  and  allied  health  training
             programs. This project has also  pointed  out  and  clarified  future
             needs in the delivery of health care in  respiratory  disease  at  the
             community level.  These needs form the basis of the renewal proposal.
             There will be a continuation of the  screening  program  for  selected
             population groups in the twelve county-San Jacinto area.  This
             activity will be rapidly advanced by the  availability  of  a  unique
             technique for the photo scanning  and  computer  storage  of  information
             obtained by the screening expirogram.  The  resulting  data  will  be  used
             not only for educational purposes but also  for  both  horizontal  and
             longitudinal studies of prevalence, incidence  and  courses  of  all  stages
             of identified respiratory disease.  To date, there have been approximately
             2,500 persons screened, 492 of whom  were  diagnosed  as  having  chronic
             bronchitis.





            Texas Regional Medical Program           -5-          RM 00007  7/@0.1


            The base staff organization at Baylor College of Medicine will
            remain largely intact without significant RMP support of pro-
            fessional personnel and will continue to serve as a center for
            the advanced training of physicians, nurses, and allied health
            personnel in the diagnosis, treatment and rehabilitation of
            respiratory illness.

            Through cooperative arrangements with The University of Texas
            School of Public Health, the prevalence and incidence data
            gathered by the screening program will be analyzed on a  con-
            tinuing basis.  Techniques to obtain representative samples
            of the population in rural areas are being developed.

            A program of nursing education activities will continue  with
            the coordination and direction of an RMP-supported nurse
            coordinator.


            The Region believes this request for third-yeat support at  a
            reduced level of funding will permit the preceding two  years
            of groundwork to serve effectively in establishing at the
            community level the increase and improvement in health re-
            sources for the management of chronic respiratory problems.
            Second Year:  None                      Third Year:  None          Requested
            Project #48 - Care of Patients Requiring Mechanical Ventilation    First Year
                          (based at University of Texas Medical School -  San   $26,717
                          Anto       This project proposes to train registered
            nurses and other nursing personnel in the total care of  patients
            who require prolonged mechanical ventilatory assistance or  total
            mechanical control of ventilation. The need has  been  manifested
            by requests from hospitals in South Texas for consultation in the
            design of intensive care units and by direct observation of the
            relative lack of training of the personnel who provide the care
            of patients requiring prolonged mechanical ventilation.

            The proposed project will establish intensive two-day  in-service
            programs of continuing education for nurses in community hospita  s,
            utilizing audio-visual aids, manuals of instruction,  demonstrations,
            seminars, and bedside supervision.

            Each hospital requesting this program will be visited to estimate the
            demand for prolonged mechanical ventilation, determine the  available
            resources, and test the knowledge and competence of the personnel who
            will take the course.  This pre-testing will be accomplished by means
            of a multiple choice questionnaire. The curriculum of the  course  to
            be presented at each hospital will be determined by the results of
            this questionnaire. The same questionnaire will  be  administered
            immediately after the conclusion of the course to assess immediate
            recall. Follow-up evaluation will be made five to six  months  later




             Texas Regional Medical Program        -6-            RM  00007  7/70.1

             by a site visit which w'ill re-check all points covered in the pre-
             evaluation, plus modifications and innovations remaining in effect
             as a result of the course.
             This program is aimed primarily at the continuing education of pro-
             fessional personnel to increase the skilled delivery of specialized
             care to patients who are in urgent need of such services and for
             whom the quality and availability of such services are limited in
             many of the smaller community hospitals. The application  states  that
             it does not duplicate the operational projects, "Area-Wide Total
             Respiratory Care", "Helping Hospitals Organize and Strengthen
             Inhalation Therapy Patient Care Programs" or "Coronary  Care  Training
             in Community Hospitals", but rather complements  these  programs.  The
             areas of shared concern, e.g., pulmonary physiology and mechanical
             aids to ventilation, provide a basis for cooperative and  interrelated
             programs of training and instruction.
             Second Year:  $16,422                     Third Year:  $15,607
             Project #49 - A Centralized Electrocardiographic Analysis         sted
                                                                          First Year
                                                                   ve      $123,006
             the local delivery of health care through prompt, expert
             electrocardiographic diagnostic services from a centralized
             base. Its possible expansion and usefulness in many other
             areas in the Region is anticipated following proved achieve-
             ment of the objectives of the project.
             This project is based at Scott and White Hospital and Clinic in
             Temple, Texas, and will serve a six-county area of Central Texas.
             This institution has provided requested EKG consultation for
             physicians and hospitals for some time but has been dissatisfied
             with the quality of service that could be rendered due to  non-
             uniform equipment, variable technician capabilities, and delays
             in receiving the tracings and returning the interpretations  by
             mail.  For the past two years a data phone system between Scott
             and White and two other hospitals has been utilized,  providing
             better, more uniform tracings and prompt reporting.  The increased
             utilization of this service, plus requests from  additional  community
             physicians and community hospitals, has stimulated this  proposal  for
             a centralized system to provide improvements in technical quality,
             rapid transmission, same-day interpretation, increased stora2e caDabili.tiy,
             and vector loop capability.
             A three channel Scalar and Loop Electrocardiograph specially designed
             for data phone transmission,using three Frequency Multiplex Signals
             and separate telephone lines at each participating hospital,  will  be
             installed. This will extend to eight hospitals  with  approximately  a
             300-bed capacity.  The automatic central recording unit will be
             capable of microfilm IBM card reproduction of 12 Lead Scalar EKG
             plus the Frank System Vector Loops.  It is recognized that vector






            Texas Regional Medical Program      -7-             RM 00007 7/70.1


            capability represents a research phase, but it is pointed out that
            this adds relatively little to the overall equipment budget.  The
            budget was felt by the local review groups to be justified by the
            project objectives, and sufficient grant-generated income is
            anticipated to repay the equipment cost in two to three years as
            the project becomes self-sustaining.  The equipment will lend itself
            readily to the anticipated computerized interpretation of electro-
            cardiograms.  Readings will be provided twice a day by telephone
            (immediately, in an emergency) and copies mailed to each participating
            institution and physician daily.  The maximum volume the system may
            handle is approximately 500 tracings per day.  The project will be
            initiated by orientation programs at the action base with staff
            physicains and technicians from praticipating hospitals.  Experience
            will be reviewed quarterly with the participating hospitals and
            deficiencies revealed will be corrected at that time.  These meetings
            will serve a continuing education function as well as a service
            review.


            Second Year:  $38,397                     Third  Year:  $39,662







                          Texas Regional Medical Program                        -8-                      101 00007     7/70.1


                                                                    History Supplement


                          Project                                      Title                      Current Support        Initiation
                                                                                                       (d.c.o.)             Date


                                I               Medical Cenetics (MDA)                                 $  26,748            7/68

                                2               Child Welfare Workers Training (MDA)                            Approved/Unfunded

                                3               East Texas Teaching Chain (Grad. Div.)                 RMP   Support   Terminated

                                4               Inhalation Therapy Patient Care Programs               $  50,000            7/68
                                                (Methodist)

                                5               Regional Consultation in Radiotherapy (MDA)              60,000             7/68

                                6               Consultation Service in Medical Physics (MDA)            49,584             7/68

                                7               Cancer Survey (MDA)                                    RMP   Support   Terminated

                                8               Statewide Cancer Registry (Houston)                      80,000             7/68

                                9               Educational Television (Grad. Div.)                      Disapproved

                              10                Microwave System Development (@IDA)                      Disapproved

                              11                Consultation Services - RadiDtherapy                     Disapproved
                                                via   Television   (MDA)

                              12                Dissemination of Cancer Literature (MDA)                 Disapproved

                              13                Communication Study (MDA)                                Disapproved

                              14                Stroke Demonstration (Dallas)                          Extended without     7/68
                                                                                                       additional funds

                              15                Area-Wide Total Respiratory Care                       242,915              7/68
                                                (12 counties)

                              16                Rehabilitation Program A (Baylor)                      127,063              7/68

                              17                Rehabilitation Program B (San Antonio)                   67,607             7/68

                              18                Rehabilitation Program C (Dallas)                        74,620             7/68

                              19                Cardiac Work Evaluation (Baylor)                       RMP   Support   Terminated

                              20                Eradication of Cervical Cancer                           90,000             7/68
                                                (San Antonio)

                                                PLANNING   CORE   STAFFS

                              21                Coordinator's     Office                               721,219              7/68

                              22                San Antonio UT                                           15,000             7/68

                              23                Dallas UT                                                3,260              7/68

                              24                Galveston UT                                             4,349              7/68

                              25                Dental Branch UT                                       Support Terminated

                              26                UT   Graduate   Division  Houston                        11,500             7/68






                           I xas Rc@giLDnal @ledical Pro2ram                      -9-                     @t   00007 7/70.1




                                27 & 28          !,I.D. Anderson                                               9,500          7/68

                                29               Baylor                                                   27,725              7/68

                                30               Methodist @i,)spital - Allied Health                     13,000              7/68

                                31               Long Distance Telephone Consultati.c)n                   35,000*             10/69
                                                 (Dallas)


                                32               Cardiovascular Nursing Institutes                        Unfunded
                                                 (Texas @4omen's U.)

                                33               Coronary Care Nurse Training in                          84,000              10/69
                                                 Community Hospitals (St. Josepti's and
                                                 Riverside Hospitals)

                                34               Regional Coronary Care & Training by                     Disapproved
                                                 Computer (Galveston)

                                35               Reduce Complications Following Radiotherapy              37,000*             10/69
                                                 (Dental Branch - Houston)

                                36               Inter-Regional Cooperative Serial Control                28,000*             10/69
                                                 Systems in South Central Library Region
                                                 (Statewide)

                                37               Health Careers Personnel Program (Statewide)             29,801*             10/69

                                38               Dial Access (MDA)                                        16,50(Y,            10/69

                                39               Annual Clinical Conference (MDA)                         15,000-             10/69

                                40               CE in CVD, Coronary Care and Intensive                   Unfunded
                                                 Care (Galveston)

                                41               Social Workers' Training in Neoplasia (MDA)              Approved/    Unfunded

                                42               CE for Occupational Therapists (Dallas)                  24,000-,-           10/69

                                43               Educational Media Instructional Program for              17,500*             10/69
                                                 Allied Health Educators (Baylor & Methodist)

                                44               Health Occupations Improvement (Multiple                 Deferred
                                                 locations)

                                45               Rehabilitation Management (Baylor)                       160,00@,            10/69

                                46               Maxillofacial Prosthetic Services (Multiple)             ioo,ooo*            10/69

                                47               Planning a Neighborhood Health Center                    Withdrawn



                                                   Funded from carryover









                                                                                                          DRMP/GRB
                                                                                                          5/28/70




                                                           A Pi7ivil-eged Communication



                                SUMMARY OF IIEVIEW A14D CONCLUSION OF
                                     JUNE 1970 RF@,VIE14 C014MITTEE


                                  TEXAS REGIONAL MEDICAL PROGRAM
                                         RM 00007 7/70.1


                          FOR CONSIDERATION BY JULY 1970 ADVISORY,'COUNCIL


              Ceneral:  The reviewers recalled that the history of the Texas Regional
                        Medical Program was a long and interesting one.  They noted
                        that the Pegion's early growing pains seem to be over, as
              judged by the last site visit in April 1969, and  staff  reports  of  interim
              organizational- activity.  The present application contains renewal
              requests for three ongoing projects and supplemental requests for two
              new projects. Committee recommended  partial  approval  of  the  application;
              approval. with specific conditions and funding restrictions for the three
              renewals and non-approval for the two new activities.

              Project #8R - Statewide Cancer Repistrv Svstem.

              Critique:  The reviewers thought the Cancer Registry System seemed to
                         be moving forward satisfactorily and that it had captured
                         the attention of some of the appropriate groups in the
              oncologic power structure in the State of Texas.    There was  some  concern,
              however, about the relationship of this registry to the existing registries
              in Texas, particularly the one at  M.D.  Anderson.  Furthermore,  the  appli-
              cation addresses itself only to the upcoming  year  of  activities,  although
              three years' support is requested.  There is no indication of what wil-1
              be accomplished in the second and third years.  There  is  also  no  evidence
            ,as to how this activity is expected to be financed at the,close of the
              period of requested support.  Some reviewers requested a clarification
              of the source of the registry's data base.  A site visit was considered
              necessary.

              Recommendation:  Approval I in the time and amount requested with specific
                               conditions:


                  1.  That a technical- site visit team be satisfied as to the
                       Committee@ four points of concern, i.e.:

                                         I
                            a.  relationship of the project to existing registries;
                            b.  plans for the second and third years of requested
                                support;
                            C.  future funding of the activity and @ phase-out;
                            d.  clarification of the source of data base.


                  2.   In the event the technical site team has not made its recolainencia-
                       tions before the end of the current: budget period, the  ixqard  for





              TEXAS Regional @ledi.cal Program          -2-              RM 00047


                        this project will carry a restriction on    the use of  any  funds
                        above.the current level of expenditure.    Approval  by  the  site
                        team will lift the restriction.

              01 Year:  @184,396         02 Year:  $132,251              Year:  $97,542

              Project #14R - Stroke Demonstration Po ram  or P@o   ssive Patient Care.

                          Despite the delays in the construction of    the stroke unit,
                          most of the staff for this project is now    on hand  and  seems
                          to be well qualified.  Howeveri  the  application  itself  is
              deficient in that it contains no  indication  of  the  number  of  physicians
              or nurses who will be trained during  the  three  years  for  which  support
              is requested and no estimates of the amount  of  time  which  will  go  into
              the poor]-y-defined external  educational  programs  in  community  hospitals
              or the advice  and  consultation  activities  for  community  hospitals.  The
              Co,nmittee reviewers, therefore, found it  impossible  to  determine  the
              educational cost/benefits of thp- activities.  Further, the proposal
              contains no clear discussion of  the  intents  during  the  second  an  thir
              years of the grant.renewal request.  The discussion of the future support
              of the project refers to  "grant  generated  incoi@,"  but  this  apparently
              does not include 1-iospital-generated dollars.  It was felt that the
              application should be rewritten to provide the above information.

              Recommendation: Approval I in  the  time  and  amount  requested,  with  the
                                following specific conditions:

                   1.  That the request be clarified to provide:

                        a.  a clear statement of the realistic estimates    of  the  number
                            of people to be trained as well as the amount of time which
                            will go into the educational program;

                        b.  a discussion of the second and third year activities;

                        C.  an ass urance that at the completion of three years no
                            additional grant support for  the  project  will  be  requested
                            from RIJTS and a statement  of  how  hospital-g6nerated  income
                            is and will bL@ handled.


                   2. To assure continuity of  support,  the  award  for  this  project
                        will be made prior to the Conmiitteels consideration of the
                        additional material. Any  additional  funds  over  the  current
                      .level of expenditures  should  be  restricted  until  Committee/
                        Council approval.

              01 Year:  $1-96,241i      02 Year'  $164,344           03   Year:   $142,844




               TEM-,S l@,c,@gional @lc@dical Program                        RM 00047


               Project #15R -- Areawide Tot@R@-q2:Lr.atoi--y Care.
               @r           The  Committee  thought  that  this  proposal   documents   extremely
                            well the extensive cooperative arraii(yenieiits that have
                            occurred in the  pulmonary  area  as  well  as  the  sequence  of
               productive   educational and                'efforts  that  have   been   developed
                                   The region               "te successful in gar
               and are ongoing.                 has been qui                        nering
               support  for  this  project  from  multiple  sources,  and  it  is  anticipated
               that by the  completion  of  next  year  of  activities,  RMP  funds  no  longer
               will, be required.

               Recommendation:  Approval I in the time and amount requested.

               01 Year:  $80,000

               Project #48 - Care of Patiea_s@Rt-_quirin2 Mechanital Ventilation.
               @rLtigi@e:  The  Ad  Hoc  Cardiovascular  Study  Panel  concluded  that   this
                            project  was  unapprovable  on  the  following  grounds:   two   days
                            is too brief  a  time  in  which  to  adequately  and  extensively
               ]-earn the use of  mechanical  respirators;  the  curriculum  is  not  ftill-y
               described and the number of courses is not specifie       d;  and  the  budget
               appears  high  and  equipment-orieiited.   Although   some'Reviev7   Committee
               members were  not  in  agreement  that  the  proposed  courses  were  too  short
               and  the  bud-et-too  high,  disapproval.  of  this  project  was  recommended
               because the activity ,,,as considered fractionating in that mechanics
               ventilation is a technique which shoul.d be included in the general
               education of nurses.  The application also does not address the proposed
               training vis-a-vis the activities of inhalation therapists.

               Rc@commeiidatiori: Non-P.I)proval I - No DIIJIP funding recommended.

               Project #49 - A  Centralized  Electrocarcli@,rApi@iic  Analysis  Svste)ii  for
                               Si@-CouT.ity. Area of Central. Texas.
               Lr@i.c.tie: The  Com,,nittee.agreed  with  the  Ad  Hoc  Cardiovascular  Study
                            Panel that the project is wel.1- described and that there
                            exist- the  cardi.ologi-c  capabilities  necessary  to  carry  out
               the  prori-am,  There was also  consensus  between  the  Panel  and  Coimiiittee
               that  the  funding  system  described  appears  strange.  The   reviewers   were
               unable to understand why  the  charge  for  the  service  will-  be  only  $5.00
               when the  nationwide  standard  fee  is  $1.5.00.  There  was  question  as  to
               why a <slightly higher fee would not be justified as a mechanism for
               depreciating tl)e'ini.tial equipment outlay rather thin having the Federal
               Governiiieiit subsidize  the  equipment  expenses.  The  general-  feeling  was
               that  there  must  be  some  way  to  finance  this  commercial  activity  without
               cost  to  the  government.  Although  the  regional.ization  evident  in   the
               proposal was considered impressive, the Rc,-vic-,v7 Coi-nriittee  agreed  that,
               in the absence of any educational COTnpDn    cut, this service project should
               not be funded.





                   TEXAS Regional @Ic!di-cal Pro@!rai@,i                                           P,,M 000/i 7


                   Re(,oii@-penclatioi-i:  Non--Approval I - No                 funding recapiniei-ided, but
                                           with a iRessage to the Region that the regioi-ializatioi-i
                                            aspect   of    the    project    is    good      that    the    Coiamittc-,e,
                   would be happy to consider a proposil- which included                        regional education
                   in cardiac care.








                                                    SU@L,kP,Y  OF  PI'@,CO@lt.Il,'NDAT IONS


                   P r
                   and Title                                       01 Year           02 Year          03 Year           Total


                    8R     State wide. Ca cer
                                                                       $184,396      $132,251         $ 97,542          $414,189

                   14R -   Stroke Den@@oiiFtratioii
                           ProRraiii for ProRressive
                           Patient Care.                                196,244       164,344           1-@2,844             503,432


                   15R -   Areai,7ide Total Resl)irator
                           Care.                                         80,000          --O-            -0-                  80,000


                   48   -  Care of Patien s Requiriii
                           Mechanical Ventilation.                    Non--Approval. I

                   49      A Centralized El-ectrocard--
                           i@o,g,-a hic t@nalvs!-S_Sv.s.tem
                           for a Six-Coll t@y_Area of
                           Central Te@Las,                             01.1-       V@-i

                                                  TIOTAI,            $460,61".O      $296,595          $240,386         $997,621














                                                                                      DIZIIP/GIZB
                                                                                      7/13/70

































































                                                                                4



            0                                                              0                                                              4






                                REGIONAL il[EDICAL@ PROCR.AMS SERVICE
                        SUMMARY OF Aii OPERATIONAL SUPPLE24ENT GRANT APPLICATION
                                      (A Privileged Communication)

          TRI-STATE REGIONAL MEDICAL PROGRKM                      RM 00062  7/70.1
          2 Center Plaza                                          June 1970 Review Committee
          Boston,  Massachusetts  02108

          Program Coordinator:  Leona Bauffigartner,.M.D.

          Requested
          Program
          Period                      lst Year*     2nd   Year       3rd Year         TOTAL
          Direct Costs                $119,210      $   96,813       $70,667        $286,690
          Indirect Costs                34.,711         32,542        22,849          90,102

               TOTAL                  $153,921        $129,355       $93,516        $376,792
                       *(16 months)
          'History:  Following a September 1967 site visit, the Region received a   two-year
                    (December 1967-December 1.969) planning grant.  During the first year
          a total of $579,468 was made available.  Early during the second planning year
          and following a November 1968 site visit, the Region became operational.  The
          first year operational awards totaled $436,122 during the period of February 1,
          1969-December 31, 1969, for support of three projects, a Coronary Care Training
          Program for Nurses in New Hampshire and Massachusetts, a Cardiovascular Training
          and Care Program at Boston City Hospital, and a Comprehensive Cancer Care and
          Training Program at the Boston  University  Medical  Center.
          Support for the second year core staff and  planning  activities  had  been
          initially provided by a planning grant of $950,659.  In May 196 the planning
          grant was merged with the operational grant.  The amount available for core
          staff and planning activities remained the same, $950,659.
          In August 1969, Council recommended approval of a supplemental application
          consisting of two projects, #5 - Training Program on the Diagnosis and Care of
          Chronic Chest Disease and lk6 - Diet Counseling Service in Rhode island.  Also
          in August, the Region was given administrative approval to implement a feasibility
          study involving a Neighborhood Health Center in Rhode Island.  None of these
          activities were funded due to DRMP fiscal restraints.

          In November 1969, Council recommended approval of a renewed core staff support
          for one year,,as requested, at $1,348,730.  Also partial funding was recommended
          for another supplemental application containing two projects:  Project #7 -
          Looking for Gaps in Stroke Rehabilitation Care.  A study in Rhode Island  was
          not approved since it appeared to be in an early planning stage.  Project lk8 -
          Comprehensive Care of the Acute Stroke Patient was recommended for funding.
          Only the core staff application was funded and at the annualized level of the
          previous year, $994,008.
          Support for the second year of the operational grant, excluding core, was
          continued at $515,219; this amount included $102,000 of carryover funds from
          the first year to complete alterations and renovations and to purchase equip-
          ment for the cardiovascular project (#3) at Boston City Hospital.  Staff, however,




         TRI-STATE Regional Medical Program          -2-                   RM 00062  7/70.1


         found it necessary to place a  $125,300  restriction  on  the  $409,016  provided
         for the cardiovascular project pending additional information.  Due to a
         number of inherent problems, the  original  proposal  was  approved  with  specific
         conditions.  There was not sufficient evidence in the continuation application,
         nor in additional information  recently  submitted,  that  these  conditions  had
         been adequately satisfied.    The $125,300 restriction is  to  remain  in  effect
         pending a technical site visit.    The progress reports of the other two projects,
         the Coronary Care Training Program  and  the  Cancer  Care  and  Training  Program,
         indicated that each was making satisfactory progress.
         In February 1970, the Region received administrative    approval  to  use   $64,900
         of first year carryover funds  to  supplement  Central  Office  core  staff.  The
         total amount, including carryover, currently provided for core staff and
         planning activities is $1,058,508.    In April, administrative approval was also
         given to use $5,000 of carryover  funds  to  supplement  the  cancer  project.  The
         Regionis second year operational program is currently funded at $1,579,127
         (d.c.o.), of which $171.,900 is from 01 carryover.

         Two of Region's approved but unfunded projects, #6 Dietary Counseling and
         #8 Care of Acute Stroke Patients, are to be funded  in  FY  1970  from  the
         recently released $5 million of the $20  million  carried  forward  from  FY  1969.
         In FY 1971  DPM  anticipates  funding  the  approved  Feasibility  Study  Involving
         a Neighborhood Health Center  from  the  remaining  $15  million  carried  forward.

         Present Application: Support is requested  for  a  single  program  in  the  area
                                of stroke.   The Region believes that this project
         exemplifies its emphasis on the attempt to fill gaps in stroke care which
         has had less attention than  cancer  and  coronary  disease.  Further,  the   three
         proposed centers in this project,  in  different  sizes  of  community  hospitals
         in very different communities, all  linked  to  Boston  University,  should
         provide improved care  of  patients,  simultaneous  education  of  the  professions
         oin the stroke team and an opportunity for competent evaluation which will
         enhance the prospect for duplicating a successful demonstration.      The   project
         in this application has been through the Tri-State review process twice,
         having been strongly endorsed in principle, but returned for improvement     in
         some aspects.

                                                                                    Requested
                                                                                    First Year
         Project #9 - Regional Centers for Diagnosis and Treatment for Victims       $119,210
                      of Stroke; A Plan for Health Care and Tr           - Under
         the administration of the Department of Neurology, Boston University
         School of Medicine, this three-year project proposes to organize
         stroke centers which will  assure  comprehensive  diagnosis  and  treatment
         of patients with cerebral vascular disease through the development of
         stroke teams at community hospitals.    The project is  to  be  implemented
         in three stages:  Stage One - organizing stroke centers at three
         hospitals in Massachusetts:    Carney Hospital, Boston; Brockton Hospital,
         Brockton and Framingham UnionHogpital, Frami@ghaLm. Stage Two - ed   ucating    and
         training members of the stroke team in the role of the team and the
         training, where necessary, of the  members  to  perform  their  tasks.  The
         team will consist of a neurologist, a fellow in cerebral vascular




         TRI-STATE Regional Medical Program       -3-                 RM 00062  7/70.1

         isease, a staff of nurses, a social worker, a physical therapist, a
         vocational rehabilitation worker, a speech therapist, and a visiting  nurse.
         Sta  Three - Analysis of the operation of the stroke centers.
         Boston University Medical Center participants will identify the  needed
         facilities and members of the stroke team and hel.p recruit, organize and
         train personnel.  The Medical Center wil,l also assist in development of
         procedures for care of the patient.  During last year (7/l/68-6/30/69) a
         total of 415 patients were admitted to the  three  hospitals.  Patients
         admitted to the to be established stroke units would in most  instances
         continue to be the private patients of the referring physicians who
         would work along with the Center Director, a neurologist, and his
         fellow in cerebral vascular disease. If a  referring  physician  cannot
         continue to care for the patient, the Center Director will be available
         to assume responsibility for the patient.  Unless  otherwise  arranged,
         patients admitted to the stroke center would be billed by the  hospital  and
         private physician.
         Training programs will be on two levels: (1) an inservice  training  program
         at the community hospital will. be conducted by the B.U.M.C.  Neurology
         Department with assistance from various medical and paramedical consultants
         and (2) a formal program conducted at B.U.M.C. School of Nursing,  to  train
         nurses either presently on the staff of the community hospital  or  new
         recruits with refresher courses in rehabilitative nursing in  order  to
         participate on the stroke team.  It is anticipated that 12 nurses will
         take this course during the first sixteen months.  A  Tentative  Course
         Syllabus is included in the application.
         Evaluation plans are presented for each of the three stages of the
         project.  Stage One will be the organizational stage which includes the
         hiring of personnel.  The second stage toward establishment of a stroke
         center is the education phase.  The third stage will provide an opportunity
         for the application of experience and will allow for defining  the  criteria
         selection of patients into the unit.
         Approximately 80% of the budget is for support of five  part-time  personnel
         positions: a Director, Coordinator, Assistant  Coordinator,  Secretary,  and
         Center Director; and two full-time positions: an  Administrative  Assistant/
         Data Technician and a Secretary. Funds are  also  requested  for  consultant
         services, equipment, travel, nurses tuition, and data processing.
         Second Year:  $96,813                          Third Year:  $70,667




                                                                          RM 00062  7/70.1
           TRI-ST&TE Regional  Medical  Program       -4-


                                      REVIEW AND FUNDING HISTORY
           (Site Visit May 1967)              12/l/67-12/31/6&              $439,037
           lst Year Planning  Award
           (Site Visited  September 1967)
           (November 1967  Council)

           ol Supplement
           (May 1968 Council)                 6/l/68-12/31/68                  92,8714

           01 Supplement
           (August 1968 Council)              9/l/68-12/31/68                 47,557
           Second Year  Planning  Award       I/l/69-12/31/69                746,770
           (Site Visit November  19.68)
           02 Supplement                      4/i/69-12/31/69                203,889
           (February 1969  Council)
           INITIAL OPERATIONAL APPLICATION  COMPONENTS
           (Site Visited November 1968)
           (November 1968  Council)
                                                                 Approved
                                                              Project Period       Funde
           #1 - Continuing Education for Physical             Disapproved with advice to res
                Therapists
           #2   Expansion and Consolidation of                3  yrs               (01)  $40,195
                @Coronary Care Training-Northern                                   (02)   36,895
                Portion of  the  Region
           #3   Inter-University Cardiovascular Pro-          3  yrs               (01)  283,716
                gram-Boston City Hospital                                          (02)  409,016 1/2/

           FIRST SUPPLEMENTAL OPERATIONAL APPLICATION
           (February 1969  Council)
           Y@4 - Comprehensive Regional Medical               3  yrs               (01)   72,701
                Program  in  Cancer                                                (02)   69,308

           SECOND SUPPLEMENTAL OPERATIONAL APPLICATION
           (August 1969 Council)
                                                            Approved     Approved, but not Funded
                                                         Project Period    lst Year Amount
           #5 - Training Program on the Diagnosis       2 yrs                            107,085
                and Care of Chronic Chest Disease
           #6 - Diet Counseling Service in Rhode        3 yrs                             45,631.
                Island



            TRI-STATE Regional Medical Program         -5-                    MA 00062    7/70.1
            REQUEST FOR SUPPORT OF FEASIBILITY STUDY
            (August 1969 - Delegated Authority)
                                                            At)provLd      Approved, but not Funded
                                                          Project Period          lst Year Amount
               roffgss for Providence (Rhode Island)                                  $  48,620
              Rea     Centers
            THIRD SUPPL34ENTAL APPLICATION
            (November 1969 Council)                                                   Funded (d.c.o.1
            #O-Core Staff and Planning Activities          I yr                       $994,008
            FOURTH SUPPLEKENTAL APPLICATION                                   ARproved - Unfunded
            (November 1969 Council)                                               lst Year
            #7 - Looking for Gaps in Stroke Rehabi-        Disapproved with advice to resubmit
                 litation Care
            #8 - @gm                                       3 yrs
                   rgiehfneivetcare of the Acute                                      $14,575 3/
                      e  a ien                                                                -
            REQUESTS TO USE 01 CARRYOVER                                              Funded (d.c.o)
            (February 1970 Administrative Action)
            #0 - Supplement to Core Staff                  1 yr                       $64,900
            (April 1970 Administrative Action)
            lf4 - Supplement to Regional Medical           1 yr                       $ 5,000
                 Program in Cancer

            FIFTH SUPPLEKENTAL APPLICATION
            (July 1970 Council)

            #9 - Regional Stroke Centers


            .I/ Includes $102,000 of 01 Carryover
            2/ $125,300 currently restricted
            3/ DRMP Funding anticipated
            (The Maine RMP, Northern New England RMP and
            'Tri-State RMP have submitted jointly, an
             application for an interregional project
             entitled--"Interregional Coronary Care
             Management Information System".  This appli-
             cation will be presented for review in early
             FY 1971).


                                                                       DRMP  5/5/70




                                                             (A Privileged Comniiiiiicati.on)


                               SUMMARY OF REVIE@L AND CONCLUSION OF
                                    JUNE 1970 REVIEW CO@,lrilTTEE


                                TRI-STATE Regional Medical Program
                                         RM 00062  7/70.1

                        FOR CONSIDERATION BY JULY  1970 ADVISORY COUNCIL

           General:  The Committee concluded that  this single  component  application
                     requesting $286,690 (d.c.o.)  for a three-year  program  period
           should be approved at the reduced amount of $253,900.

           Project #9 - Regional Center for Diagnosis and Treatment for Victims of
                        Stroke:  A Plan for Health Care and Training,.

                      The Committee found this to be a straight forward approach for
                      a program which would be under the direction of qualified
           personnel. The hospitals involved have the  necessary  equipment  and  will
           be adequately staffed.  The training programs are designed to upgrade the
           capability of existing personnel.  The only concern expressed by the
           Committee was that the project was overstaffed in the area of overall
           program direction.  The budget requests support for a Director (10%);
           a Coordinator (80%) and an Assistant  Coordinator  (50%).  The  Committee
           believed that the equivalent of one full-time physician should be adequate
           rather than the 140% time represented by these three positions.  Further,
           the amount.provided for the full-time physician should be  based  on  the
           annual salary requested for the Coordinator.

           Recommendation: Approval I provided the amount  for  personnel  be  reduced
                            each year as outlined  above.  The  approximate  amounts
           recommended for approval are $105,300 the Ist year, $85,600  the  2nd  year
           and $63,000 for the 3rd year.

           Dr. Proger was not present during the deliberation of this application.








                                                                      DRMP/CRB
                                                                      7/8/70



















            9                                                              0








                                      REGIONAL  MEDICAL   PROGRAMS   SERVICE
                          SUMMARY OF AN OPERATIONAL SLTPLEIENT GRANT APPLICATION
                                         (A Privileged Communication)



                  VIRGINIA REGIONAL MEDICAL PROGRAII.                      P.M 00049  7/70.1
                  Medical College of Virginia                              June  1970 Review Committee
                  12tti & Broad Streets
                  Richmond, Virginia  23219

                                           Eugene R. Perez, M. D.

                  Requested
                  Program
                  Period:                 lst  Year      2nd   Year      3rd   Year     TOTAL

                  Direct Costs            $268,552         $480,479        $533,504       $1,282,535
                  Indirect Costs             16,265          33,155        34,302             83,722


                  TOTAL                   $284,817         $513,634        $567,806      $1,366,2@57

                  IIISTORY:   (A list of  the  Drojects  indicating  Council  action  can  be  seen
                              on the attached Review    and Funding Ilistory.)
                  The Virginia FFY received its initial planning grant award in January
                  1967.  The  applicant  organization  was  the  University  of   Virginia   School
                  of  @fedicine  in  Charlottesville,  Virginia.  On  July  1,  1967,  Dr.  Eugene
                  R.  Perez  was  appointed  as  the  full-time  Program  Coordinator.  When   the
                  continuation application was submitted in late January  1968, the
                  responsible  fiscal  agent  was  changed  from  the  University  of  Virginia  to
                  the Medical  College  of  Virginia  in  Richmond,  now  known  As  the  Virginia
                  Commonwealth University.

                  Early in July  1968, the Virgini.a RMP submitted an operational grant
                  application requesting funds for sixteen projects.  Council did not
                  approve  operational  status  for  the  Region  but  did  approve   continuation
                  support of planning activities.

                  The Region resubmitted their initial operational grant application to
                  the December  1969, Council and site visit was made to the Region on
                  October  1-2,1969.  The  December  1969  Council  concurred   with   the   recom-
                  mendation of  the  site  visitors  and  the  Review  Committee  that  this  Region
                  be awarded operational status.  Of the seven projects in the application,
                  Council  approved  five  projects  and  disapproved  two  projects.   The   amount









                                                              RM 00049  7/70.1
         VIRGINIA                            2-
         Regional Medical Program

         of funds approved for three years by Council for this applica-
         tion totaled $1,013,746 (d.c.o.) (01 year -  $345,695,  02  year
         $330,676, 03 - $337,375).
         In February 1970, the D@T  staff  reviewed  this  Region's  con-
         tinuation application.requesting support of the core component.'
         Changes in-the staffing pattern were noted which had  a  net  effect
         of diminishing the number and total effort of physicians in   volved
         ill the core operation. Furthermore, the Region  had  expended  only
         55.1 percent of its funds.  To permit time for the Region to clarify
         tile rationale for the new staffing pattern and to project its rate
         of expenditures, an award was made at the  committed  amount  of
         $475,255 (d.c.o.) with a restriction on the use of $100,000.
         'rlic restriction is still in effect.
         In March  1970, Council approved the Region's first operational
         supplemental application requesting $662,694  (d.c.o.)  for  support
         of two,projects (#8 - State-wide Tumor Registry, #9 - Continuing
         Education for Nursing Personnel).
         PRESENT APPLICATION: This is  a  supplemental  operational  applica-
                                tion requesting a funding level of $1,282,535
         for three years support of one project.  It is Project #10
         v                                            System,  a  resubmittal
         f                                            mitted to the December
         1969 Council.  The December Council concerns about this project
         were that the project needed to better identify  the  population  it
         expected to reach, and should have included a formalized method
         for the selection of clinical testing and computer systems to be
         used.
         Project #10                                                         Requested
                                                                     This    First Year
         project is sub                                            and it     $268,552
         proposes to demonstrate through a model program ,!ays  an  means  of
         more efficiently applying new technical knowledge to the benefit of
         lTiore people through improved medical manpower utilization and economy
         of services.
         The project will develop and operate a model system of early disease
         detection which @yould demonstrate, stimulate and assist in the more-
         effective application of new disease detection methods throughout the






                  VIRGINIA                                                 RM  00049  7/70.1
                  Regional Medical Program


                  Virginia  Regional Medical  Program.  The  center  will  be  designed
                  primarily to serve the Richmond Medical area (population 570,909)
                  and will be located at  the  Medical  College  of  Virginia  Clinical
                  Center.  The system of referral will be developed and operated
                  through a cooperative arrangement (and/or contractual agreements)
                  between the Medical College  of  Virginia,  the  Medical  College  of
                  Virginia Hospitals, and:

                       -private physicians               -official health agencies
                       -participating hospitals          -welfare Agencies
                       -medical societies                -insurance and  other  third  party
                       -voluntary health associations       payment organizations
                       -industries

                  It is expected that during the  first  year  3,000  persons  will  be
                  screened, second year of the project 10,000 people will be screened
                  and from the third year on, carry a  patient  load  of  20,000  per  year.

                  The proposed screening tests  to  be  performed  will  be  procedures
                  for the presumptive identification of:

                       -Tuberculosis                     -Syphilis
                       --Visual defects                  -Diabetes
                       -Hearing defects                  -Cancer
                       -Cardiovascular diseases

                  The model program will  also  be  utilized  for  demonstrations,  and
                  training of medical and paramedical personnel in the application of
                  multiphasic health  screening.  Some  of  these  activities  will  be:  to
                  demonstrate the application of multiphasic health screening to 50
                  selected practitioners per year; to  train  50  technicians  per  year  in
                  the performance of multiphasic health  screening  tests;  to  serve  as  a
                  laboratory demonstrating  multiphasic  health  screening  service  to  130
                  medical students per year; to serve  as  a  physical  model  for  the
                  development of other screening facilities in the Virginia Regional
                  Medical Program subregions.

                  All cases detected with suspected disease will Le referred to their
                  attending physician for a conclusive diagnosis and/or treatment.
                  Screening results and a request for a disposition will be sent to
                  physicians of patients referred from the screening center.  In
                  instances where follow-up review reports are not received by the
                  screening center, the local health department will investigate and
                  take action necessary to obtain follow-up and disposition.  Folloxq-up





             VIRGINIA                       -4-                  RM 00049@7/70.1
             Regional Medical Program

             to final disposition of each case will be coordinated by  the  screening
             center.
                                                    in this program will involve
             The evaluation criteria to be  utilized
             a study of the  following:  reliability and vadility of  tests  utilized;
             productiveness of the screening  tests; cost benefit ratio;  adequacy  of
             follow-up; and acceptance by  physician health agencies and  the  general
             population.
             In the second year of                                   ired to pay a
                                   the project, patients will be requ
             $35 service charge which will give a revenue to the program.  Because
             of this revenue, the amount of support.required from RNP grant  funds
             will decrease during the second and third years and thereafter  it  will
             be self-supporting.  The estimated budget request for 02 year is
             $480,479 (d.c.o.) and the expected revenue from the projected  10,000
             people to be screened is $350,000. The estimated budget  request  for
             03 year is $533,504 (d.c.o.) and the expected revenue from the pro--
             jected 20,000 people to be screened is $455,000.  If the projected
             revenue for 02 and 03 years are realized the total support from the
             DPJFP will be approximately $130,479 (d.c.o.) for 02 year and $78,504
             (d.c.o.) for 03 year. Construction costs and major  capital  outlay  for
             equipment will be supported on a matching basis between the Medical
             College of Virginia and the Hill-Burton Program.  The major portion
             of funds requested from the DRY? are for personnel and rental  cost  for
             space in the Clinical Center.
             Second Year:  $480 479                    Third Year:  $533,504






                 VIRGINIA                           -5-                RM 00049 7/70.1
                 Regional  Medical  Program




                                       REVIEW AND FUNDING HISTORY

                 Ist-Year Planning Award      I/l/67-12/31/67     Amount of AAard $226,800 (d.c.6.)
                 (University  of  Virginia)
                 2nd-Year Planning Award      3/l/68-2/28/69      Amount of Award $254,000 (d.c.o.)
                 (Grantee organization
                 changed to the Medical
                 College of  Virginia,  now
                 known as the Virginia
                 Commonwealth   University)
                 Planning Renewal Award       311/69-2/27/72      Amount of Award $475,255 (d.c.o.)
                 (An  operational  applica-
                 tion was submitted  to  the
                 November  1968 Council which
                 included  16  projects.  It
                 was disapproved by Council
                 and instead  this  renewal
                 award for  Core  planning  was
                 approved.)

                 Initial Operational Award  1/l/70-12/31/70       Funded
                 (Submitted to December                           01  -   $   345,695
                 1969 Council) (Site visit-                       Commitment
                 October 1-2,  1969)  (Award                      02  -      330,776
                 Pending Availability of Funds)                   03  -      337,375
                                                                          $1,013,846 (d.c.o.)


                 PROJECTS

                 #1 - Myocardial Infarctiort                      Funded
                 Training  Program  (Medical                      01  -   $   118,000
                 College of Virginia) (Previously                 Commitment
                 submitted and revised) (req. 01                  02  -      118,000
                 $223,792)                                        03  -      118,000

                 #2 - Coronary Care Evaluation                    Funded
                 (University  of  Virginia)                       01      $    50,306
                 (req.  01 - $50,306)                             Coinmitmen-t
                                                                  02           50,306
                                                                  03           50,306







                                           -6-                       00049 7/70.1
           VIRGINIA
           Regional Medical Program


           #3 - Cardiovascular                            Funded
           Resucitation  Training                         01 -  $48,589
           (req. 01 - $75,865)                            Commitment
                                                          02 -   39,995
                                                          03 -   41,294

           #4 - Stroke in a Small                         Funded
           Rural Community  (req4                         01 -  $63,800
           ol - $73,375)                                  Commitment
                                                          02  -  57,375
                                                          03  -  62,775

           #5 - Stroke Program and                        NON-APPROVAL
           Training Unit (Medical                         Revision Required
           College of  Virginia)'
           (req. 01 -  $308,800)
             6 - Virginia  Model                          NON-APPROVAL
           Multiphasic Health Screening                   Revision Required
           System - (req. 01 - $253,662)
           #7 - Virginia  Medical                         Funded
           information System                             01 -  $65,000
           (req. 01 -  $124,010)                          Commitment
                                                          02  -  65,000
                                                          03 -  65,000

           First Operational Supplemental
           Application (March  1970 Council)

           #8 - State-wide Tumor Registry                 APPROVED
           (reqi 01 -  $113,584)
           #9 - Continuing Education for                  APPROVED
           Nursing Personnel (req. 01 -
           $111,860)



           #10 - Virginia Model Multiphasic               UNDER  REVIEW
           health Screening System (req. 01
           $284,817) (resubmittal)






                                                                                      izi@i oool@@,  7/--,o. I



               STAI@F  Or-,,S!',')@VATTO@',:

               Project i,'-IO                                   Ileiltli Scr(@@eril.ri Systeir,:  (17irgiril.,l
                                Co!rlqlorii,7c@ a 1-th U ii i v c i.-y

               Addendu :    Subsequent to the Rcvie@.? Cot-,ilitittce          a revised budget eyes
                            received frooi the Vfl,!,'!P viLiic'ii decreases the direct cost and
               increases the indirect cost requested in the btjcl(,et submitted with the
               application,  The  direct  cost  was  reduced   because   the   Rea@A.on   descovered
               that the facility which           house the project is oi@!ried by the  Vir@,i,r).i-a
               Cori,inoni,2e,ilth Universi.ty(Graricce) lnd it is inappropriate to cl-iargc-,. rental
               for space to this project.   The indirect cost  @,7as increased because the
               on-caiapus overhead rate for salaries and. visages is higher than the previously
               requested off-canipus overhead rate.

               The Coiaraittee's recoiii.@-@i(-,ndations should be imciiclc@cl as follows:

                                                                (Direct CoE;t)

                                           Initial           Coni  '.giittec             Ainend,,?,d
                                 Y e a r   Request           R e c c) iyt,-ii e n d a t i o i-i R e q ti c@ s t

                                   01       $268,552            $268,552                    $252,302
                                   02      480,1@79             480,z@79                    447,979
                                   03      533,504              533,504                      501,004

               'j'OTAL (d.c.o.)          $1@282,535          $1.@282,535                $1,201-,285









                                                                           RI,IPS /G:@ZB/ 7 /].O/ 7 0





                                                                           A Pi:i.vilegecl  Communication





                                       SU-.\2,,'ARY OF REVIEW AND CONCLUSION OF
                                            JUIE 1970 REVIEIJ COI,.UilT'J'EE


                                        VIRGINIA REGIONAL l,@EDIC@IAL PROGRAM
                                                   Pd4 00049 7/70.1


                               FOR CONSIDERAJ'101\1 BY JIJLY 1.970 ADI%FSOI@Y COUNCIL



               Geh6r8l:  The Review Committee concluded that this application which requests
                           $1,282,535  (d.c.o.)  for  a  tlirc,.c.-year  program  period  be  approved
               with conditions at the requested level for three years support of 'Project #10-
               Vir5zini@,). 14odel. I.,,Iul,@kpiLisiS        enin,, S s@.el-n_.
                                              _I,,Iealth Scrc----,--.L_

                      u@i-.id:  Vnis project       submitted  to  the  December  1969   Council   and
                               was  disapproved.  The   December   Council's   concerns   about   this
               project  were  that  the  project  n@eded  to  better  identify  the   population   it
               pxpe6ted  to  reach  and  should  include  a  formalized  method  for   the   selection
               of clinical testing and computer systems to be used.

               Project  i,'-IO - Virginia liociel, Miil.tipl@),lsic Ileo-Itji c)crctei) stem:     (VrRi.nia


               L@i Li (fue: Committee believed that this       application represents a marked
                            improvement over the previous        application.  Many   of   the   pr.-vicwus,
               problems   have   been   corrected.   The    traini-ng, education and evaluation
               components have been developed in greater (retail. and str@nthened.              C o o p e rl t i-,:v o-
               arrangements have been documented.         Concultiti.,c)n 1-ias been;6btiined  on  ti-ie
               selection  of  screening  tests  and  on  the   use   of   computers   respectively   from
               the clinical staff of the  liedical  Colle  c@  of  Virt;,i,t-iia  and  from  the  Mitre
                                                              9          C>
               Corporation.     However, the project still ]-ins ).r@eas of weakness        such  as   no
               guaranteed  adequat-e  patient  intake  -in(J  specifics  oil  how  the   computer   time
               r(-,quested x,)ill@ be ut:il.i.7,ed.

               An  influencing  factor  on  Co@nt,.iittee's  decision  to  approve  this  project,.  is
               the progrqdi's projection for,- revei'lue iqlij.cl-i  will  allow  it  to  assume  the  major
               portion of support for the program                 !.is second Fired third year and
               henceforth.

               Committee would lil,-,e tlir-- Region to  I)rovid   a mechanism through which
                                                                 e
               patient intake and revenue can be-9       Llarai:itced, -is ones  been  projected  in  the
               second 6tid third )rear of the project.        Although the patient follow-up
               plan 1-in@- been improveci@ Cc,,-iiii)ittee believes it can  be  furti-ier  strengthened.
               Recominc.,nd,itio).-t: Approval  I  -  provided  the  ]@@(@pion  submit  additional   iiiform@3-
                                    note  showings  (a)  That  the  Region  can   provide   a   mechanism
               which wi  I-1, guarantee the patient intense iLid revenue which it has projected.
               (b) 'fix,)t the Regioi.-i c;Ftri cldc@(.Iuately justify the amount of cot@iputkr name
               it has r6quested.      If not, the amount reqi.iesl--c(l for this iterii should be,,
               deleted vt:ien the          year's award is cranted.

                     F i. I- @,,- t - y ea I-              Second Y(@at-                  Third    Year
                     $968,552                             $480,479                        @533,50141-






             VIRGINIA M4P                                                  RM 0004@9 7/10.1






                             RE@VIEW COi@itll'ffEE FUNDING RECOIt4ENDATIONS



                 ect            Year                @m U-e -@ @             Recoftimended

             #10                 01                 $268,552               $268,552
                                 02                  480,479               480,479
                                 03                  533.501@--             533@ 01

                             TOTAL                $1,282,535              $1,282,535














                                                       @,'PS/GRB/7/10/70

















            0                                                               0                                                            0




                                                             A  Privil-eged'CormDunication



                                               SPECIAL ACTION
                                    VIRCINIA REGIONAL @fl,'@DICAL PROGRAM
                                                PdA 000@9




                                                        'I]-, Rural Cominun    -   Medical
                   ect-  Project #4 - Stroke in A Sma
                                          ollege of Virginia

               Request:-  The  Virginia  Regional  Medical  Program  has  requested   that the
                          restriction from the  NAC  on  Project  #4  be  lifted  so  that the
                          program  can  be  activated.  The  approved  level  of   funding is
               as fol.lo,,7s: 01 year - $73,375;  02  year  -  $64,050;  03  year.-  $71,050;
               a total of $208,475 for three-years support.

               Background:  The  Virginia  Regional  Medical  Program  submitted  to   the
                            December  1969  Council  as  one  of  its  initial  operational
                            proposals Project #4  -  Stroke  in  A  Rural  Coinniu@.  .  Council
               action on this project  was  Approval  I,  as  recommended  by  the  site  visit
               team, contingent upon  the  necessary  certification  of  the  Maple  La@,Tn
               Nursing Home by Medicare as an extended care facility.  This program
               will study the  incidence  of  stroke  and  the  management  of  patients  with
               stroke  by  general  practitioners  in  a  rural  community.  It  will  attempt
               to discover what changes are, needed  and  what  changes  can  be  made  in  the
               pattern of care  of  patients  with  stroke  by  general  practitioners  in  a
               rural  community.  This  will  be  done  by  close  and  regular  consultation
               with specialists from  the  medical-  center  coming  to  the  rural  community
               and by providing for  further  training  of  the  local-  personnel,  both  in
               their home community and the Medical Center.  The small community in
               which this study is  to  be  done  is  Blackstone,  Virginia  with  a  population
               of 5,000 and  is  located  approximately  70  miles  from  the  Medical  College
               of Virginia.  In the community there are three general practitioners
               who have a  group  practice,  a  physical  therapist  and  two  Public  Health
               Nurses.  In  addition  to  the  three  physicians  in  Blackstone,  there  are
               general practitioners in four small.. adjacent towns  and  all.  have  agrees,,
               to cooperate in the program.

               A site visit' to this Region @7as condi.ictccl. in October 1969 and the
               visitors noted that  the  problems  with  Project  #4  were  basically  the  same
               as those reflected by a  previous  site  teaiu;  specific-,ally,  that  the
               @lapl-e La@,7n Nursin- I'@ofiie is functioning as an intermediate! care facility
               but  is  not  accredited  to  receive  Medicare  services.  The  site  visit
               team, however,  was  impressed  that  the  proposal  has  been  expanded  to
               incl-ude the participation  of  seven  community  physicians  from  the  sur--
               rounding areas. The  proposal  has  a]-so  been  expanded  to  involve  the-
               community  physicians  in  the  training  of  other  practicing   physicians
               through the Region.  These  additional-  activities  and  the,  fact  that  one
               of the general practitioners  in.vol.ved  in  the  program  is  the  President
               of Virginia Academy of General  Practice,  were  considered  addc@d  stuci)gtl-i.






              SPECIAL ACTION - Virginia Ri@iL-1           -2-             @l 00049


              The site visit team felt the program had the pot.       ial outreach to
              strengthen  much-needed regional.j.zation for thi.,,@   4,,j.on, since it
              involves the Medical Center, community Iiospitals, community physi-
              ciaris, nurses, etc.

              The Virginia Regional- Medical Program  has  indicated  that  the  lack  of
              certification for the Maple Ila@,7n Nursing Iloine steiiis froiTi: (a) the
              Ilome not providing 24-hour nursing service and (b) certain architectural
              deficiencies.  Recent information received from the. Region informs
              us that the nursing home has  been  purchased  by  a  large  nursing  home
              corporation,  Progressive  Care,  Incorporated.  The  new  owners   have
              indicated  that  all  deficiencies  that  have  prevented  accreditation
              by Medicare will be corrected.  Dr.  Mack  I.  Shanholtz,  State  Ilealtli
              Commissioner, contends that tiie facility complies with Medicaid
              requirements but it still lacks Medicare certification.

              The Virginia Regional  Medical  Program  also  contends  that  the  project
              and the nursing home  are  not  inter-related  except  for  an  occasional
              patient that may become part  of  the  statistical  report  of  the  study.

              The Virginia Regional Medical  Program  has  expressed  concern  that  t  e
              contingency of certification by Medicare will delay the implementation
              of this project  indefinitely.  They  have  indicated  to  staff  that  the
              project has a high priority a-,id  have  requested  that  the  restriction
              be lifted.


              Staff recommends that Council consider a temporary waiver of the
              restriction so that the project can be implemented iiyi-i-ciediatc-ly, subject
              to the condition that all deficiencies are corrected by December 31, 1970.
              This date is six -months subsequent to new ownership and coincides with
              the end of the  current  grant  period.  This  should  allow  the  facility
              sufficient time for alterations and renovations to be implemented I.iid
              the initiation of 24-liour nursing services that Medicare certification
              requires.



















                                                 D PIIP C 1-1@B
                                                 7/10/70


















            a                                                              0                                                              0








                               REGIONAL MEDICAL PROGRAMS SERVICE
                     SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                    (A Privileged Communication)



             REGIONAL MEDICAL PROGRAM                        Pdl 00013 7/70.1 (formerly 3/70.1)
              for WESTERN NEW YORK                           February 1970 Review Committee.
             2929 Main Street                                March 1970 Council
             Buffalo, New York  14214                        June 1970 Review Committee

             Program Coordinator:  John R. F. Ingall, 'ill-D.


             R    sted
             Program
             I-eriod              lst   Year       2nd@@Year      3rd  Year        Total

             Direct Costs       $    988,174    $   872,987     $  895,1-99      $2,756,360
             Indirect Costs          183,680        152,864         202,507         579,051


             Total                $1,171,854     $1,065,851      $1,097,706      $3,335,411

             History:  The initial planning period for the Western New York Regional
                       Medical Program began in December 1966, and the first award for
             operational support was made in March 1968.  This  Region's  annual  level  of
             support is.$1,428,915 (total costs):  $390,377  for  core  activities  and
             $1,038,538 for six   operational projects.  Two additional projects (#'s 13
             & 14) have been initiated from carryover funds.

             December 1969 Council recommended disapproval of a proposed Medical
             Genetics Clinic, but recommended approval of three  projects  in  a  total
             amount of $276,522 direct costs for the first year:  Topical Chemotherapy
             Treatment for Precancerous Lesions and Cancer of the Skin (#13), Infor-
             mation Dissemination Service (#14), and a Respiratory Intensive Care
             Unit (#3S), which is a supplement to the ongoing Project #3 - Chronic
             Respiratory Disease Program.

             A request for continuation of the present operational program will be
             submitted in mid-January 1970.

             Present Application: Support is requested  for  the  initiation  of  three
                                   projects:  A Total Regional Program in Dialysis
             (#15), a Regional Coagulation Reference Laboratory (#16), and A Regional
             Program for the Prevention of  Atherosclerotic  Disease  (#17).  A  fourth
             project was originally submitted with this application--Radiotherapy
             Technician Training Program--but subsequently  was  withdrawn  because  of
             the DRMP policy not to support basic education  and  training  in  established
             health professions.






             REGIONAL MEDICAL PROGRAM
              for WESTERN NEW YORK                -2-                  RM 00013  7/70.1


                                                                       Re    ted
                                                                       First Year
             Project #15 - A Total Regional Program in Dialysis.       $623,970
                          h@is project is designed to  expand  dialysis-
             transplant services in the Region through the development of a training
             program for all levels of personnel to be centered in five hospitals,
             (Buffalo General, Deaconess, E. J. Meyer Memorial, Roswell  Park  Memorial
             Institute in Buffalo and Hamot Hospital in Erie, Pennsylvania).  It is
             hoped that the program will increase the number of patients for which
             treatment is available, develop a communications system among hospitals
             to insure referral of patients to hospitals which can provide  care,  make
             it possible to locate dialysis facilities throughout the Region, establish
             criteria for evaluating resources, and maintain a continuing education
             program and consultation service.
             The planned training program will permit each hospital to teach the
             techniques it uses with its equipment, form an integrated faculty with
             participants from each of the five hospitals, offer  appropriate  training
             aimed toward physicians, nurses, technicians, and patients' families
             (courses for other allied health personnel will be instituted at  a  later
             date), and train personnel to develop and expand the resources of the
             Kidney Bank and Research Society of Buffalo and Western New York.
             The training courses which have been planned are approximately six
             weeks in duration, and outlines of the content of each are provided as
             appendices.
                  1.            .  This program will consist of three parts:  didactic,
             clinical observation and instruction in each of the five centers, and
             four weeks at the hospital of the participant's choice.  The trainee
             could also accept a several-month fellowship, either at one of the
             participating hospitals or rotating among them.  Funds for six such
             fellowships are requested.
                  2.  Nurses.  During the first two weeks the theory and factual basis
             for dialy 1  transplant treatment will be presented. ;The last four weeks
             will be devoted to clinical experience, during which time the  nurse  will
             learn to operate the equipment and provide optimal care to the patient.
             Conferences will be scheduled occasionally during the six weeks.
                  3.  Technicians.  In the course for nurse technicians, mechanical
             technicians and laboratory technicians, the initial two weeks will be
             spent on the theory and background of dialysis, and the remainder of
             the time on clinical experience appropriate to each type of technicians
             There will also be conferences.
                  4. Families of Patients on Home Dialvsis.  The  training  will  start
             with two weeks of theory and background information (during which time
             the trainee will also observe dialysis in the hospital), followed by







             REGIONAI, MEDICAL PROGRAM
               for WESTERN NEW YOPI@                   3-                  RM  00013  7/70.1


             several weeks of actual dialysis performance in the hospital under
             supervision, and terminating with a period of the trainees performing
             home dialysis with hospital personnel available for consultation.  The
             length of this final period of  training  will  vary  according  to  individual
             need.  Thereafter, the families will be encouraged to participate in
             periodic group discussions.
             It is estimated that 20 physicians and 100 nurses and technicians will
             receive training, with their hospitals paying their full salaries dur     4 ng
             the six-week training period and the grants providing $12 per day
             allowance.  Ultimately, it is hoped that the employing hospitals will
             assume the latter expense.
             Evaluation techniques will  include  pre-  and  post-training  tests,  faculty
             evaluation of trainees, and  six-n@onth  follow-up  assessments  by  employing
             institutions.  When the program has had more experience, an evaluation
             of its impact on the community will be undertaken.
             The major portion of the requested budget is concentrated in the categories
             of personnel and  "other."  "Other"  includes  funds  for  fellowships,  labor-
             atory tests, costs of blood, reimbursement to participating hospitals,
             maintenance.and repair of equipment and per diem for trainees.

             Second Year:  $615,856                        Third Year:  $625,722

                                                                           Requested
                                                                           -Fl r,-3  Y@e a r
             Project #16 -                                                 $256,041
             blood coagulation reference laboratory which would have training,
             service, and research components.  Although Roswell Park Memorial
             Institute has been providing some  free  services  in  this  field,  increasing
             community needs and decreasing funds for Roswell Park have prompted the
             submission of this proposal.

             An education program will  be  developed  which  will  include:
                  1.  Medical Laboratory Technician Training.  Students at the SUNY
             Buffalo Department of  Medical  Technology  will  receive  instruction  within
             the framework of the school's  course  in  hematology  and  practical  experi-
             ence in the laboratory itself (approximately 50 lectures and demonstrations
             per year), laboratory training will be provided technicians from community
             hospitals, and graduate laboratory technicians will participate in
             quarterly, week-long seminars and workshops.
                   2.  Medical Students.  Approximately 25 hours annually will be
             devoted to lectures and demonstrations in hemostasis and blood coagulation
             problems (will be incorporated into the Medical School's curriculum),






             ,,EGIONAL MEDICAL PROGRAM
               for WESTERN NEW YORK                 -4-                  RM  00013  7/70.1


             third and fourth year students on clinical  services  will  have  access
             to consultations with the staff, and summer fellowships in coagulation
             will be available through the School of Medicine.

                  3.  Post-Graduate Training.  Periodic lectures, laboratory demon-
             strations, films and videos will be offered  in  cooperation  with  the
             Department of Post-Graduate Medical  Education.  The  laboratory  will  also
             offer an intensive two-week course each year,  and  participate  in  two
             separate hematology fellowship programs.  It is hoped that this educational
             program will produce an increase  in  experienced  coagulation  medical
             personnel and provide well-trained technicians for community hospitals.
             The proposal calls for the provision of clinical consultation ser,lices
             to physicians. Laboratory consultation  service  will  also  be  offered
             because, although the laboratory will not  perform  any  routine  coagulation
             studies for area hospitals, in order to have  clinical  material  avai  a  e
             for the various training and testing programs,  it  is  considered  necessary
             for the laboratory to engage in limited clinical service.  One hundred twenty
             cases per month is the estimated load of hematologic workups for more
             complex problems of blood  coagulation  and  hematosis.  Special  diagnostic
             reagents and sera will be prepared and made available,  work  will  be  done
             on standardizing tests, and a voluntary program of quality control will
             be  conducted.

             Research  will not be emphasized, but will  be  conducted  as  necessary.

             The  requested costs are primarily for personnel and equipment.
             Second Year:  $183,282                      Third Year:  $192,186

                                                                         Re      ted
                                                                         First   Year
             Project #17  -                                              $108,163
                           Atherosclerotic Disease.  In an effort to
             identify people in the Region with a high risk  for  heart  disease  and
             stroke, a reference lipid laboratory will  be  established  to  measure
             serum cholesterol, serum triglyceride, and lipoprotein electrophoresis
             on the following high-risk groups:

                  1.  Patients with coronary artery disease
                  2.  Patients with peripheral vascular disease
                  3.  Patients with xanthomata
                  4.  First-degree relatives of hyperlipemics.
             Although cholesterol determinations are being  performed  now  in  many
             hospital laboratories in the Region,  neither  triglyceride  nor  lipoprotein
             electrophoresis measurements are available on a service basis.  The proposal
             states that in order to diagnose the exact lipid abnormality and prescribe
             the proper therapy, all these measurements must be performed.







           RLGIONAL MEDICAL PROGRAM
              for WESTERN NEW YORK                -5-                 RM 00013 7/70.1



           According to the proposed protocol, all chemical determinations on  the
           blood sera will be done locally and the sera will then be shipped to
           the central laboratory where lipid analyses will be performed at no charge
           to the high-risk patients.  The laboratory test results will be furnished
           the referring physician as well as the clinical director and nutritionist
           consultant of this study who will recommend to the physician  appropriate
           diet and drug therapy.  All therapeutic decisions are ultimately, however,
           those of the patients' private physicians. On request of  the  physician,
           the proposed program will also offer direct dietary counseling  service
           to the patient (either by telephone or in person if the patient can travel
           to Buffalo) and provide specific dietary recommendations and  appropriate
           teaching materials to the physician. The nutritionist will  also  work
           on developing new approaches to patient teaching. Therapy  evaluation  is
           planned. -It is hoped that the program will be self-supporting  within
           three years.

           The requested budget is primarily for personnel and equipment costs.

           Second Year:  $73,849                      Third Year:  $77,291



                   :  February 1970 Review Committee

            General: The Review Committee recommended that  all  three  projects
                      i.-n this application receive a technical site visit and
            be returned to Committee.  It was observed that the Western New
            York Region is one of the better RMP'S:  it is well organized)
            well managed, and has a reasonable spread of regional activities.
            The Committee noted that two of the projects in the  current  appli-
            cation (#'s 16 & 17) signify a trend of moving toward a series of
            isolated specialized laboratories instead of general diagnostic
            laboratories, and was curious as to the economics of such a tren

            Project #15 - A Total Regional Program in Dialysis
                       Committee agreed with the Kidney Disease Program,  Regional
                       Medical Programs, that the proposed dialysis  project  is
            truly comprehensive with a well-organized plan of operation.  The
            educational programs were considered excellent. The  proposal  speaks
            not only to the technological aspects of dialysis, but the social
            problems brought about by the impact of technology upon the patient
            ate also considered.

            The Kidney Disease Program questioned the wisdom of establishing
            dialysis centers in five hospitals, and it suggested that the  project
            be limited to two or three hospitals. This  would  reduce  redundant
            expenditures.  There was also some concern on the part of the
            Committee about the appropriateness of the five-hospital plan,
            especially since one of the hospitals is a cancer research  institute.
            However, most Committee members approved of starting the program
            in the five hospitals, particularly in view of the fact  that  inte-
            gration of activities is planned.  The Kidney Disease Program
            further had questions about some items of equipment, equipment  main-
            tenance costs, and the lack of information regarding  the  intention





            REGIONAL MEDICAL PROGRAM
              f,Dr WESTERN NEW YORK            - 6 -                RM00013 7/70.1



            Other questions of the Committee included:

                  1.  Is the New York Kidney Institute at Albany involved in this
                      project and is this application to set up an alternate Kidney
                      Institute in the Western part of the State?

                  2.  Why is $62,500 requested for hospital costs?  Will the New
                      York Blue Cross/Blue Shield not pay for this?  It  seemed
                      to the reviewers that the dialysis program should be  able
                      to support the beds (if Blue Shield does not) and the
                      laboratory tests.

                  3.  How long does the Region envision the training  program's
                      continuing? How many people need to be trained eventually?
                      Will the educational program train only people from  the
                      Western New York Region or will it seek to provide trained
                      personnel for other Regions?
                  4.  How does the proposed program tie in or compare with  the
                      home dialysis training pr@mof Central New  York  (approved
                      but as yet unfunded)?
            Although the Committee seriously considered  recommending  Approval
            II (no additional funds recommended), with the amount  allocated  to
            the project not to exceed $500,000, it was decided that in  view  of
            the questions raised a technical site visit would be  worthwhile..

            Recommendation: No action taken - need technical site visit.


            Project #16 - Regional Coagulation Reference Laboratory
                       Although the Committee could see the need for improvement
                       of laboratory facilities, it was unimpressed  with  the
            teaching aspects of this proposal.  The project appeared to the reviewers
            to be primarily basic service with an educational  component  tacked
            on as an afterthought.  It was observed that Roswell Park already has
            an ongoing program in blood coagulation but that  this  institution
            is runningintofinancial difficulties and needs new sources of support.
            Eventual phasing out of RMP support is not discussed in  the  application.
            The proposal received a technical evaluation by the  Coagulation  Section,
            Laboratory of Blood and Blood Products, Division of  Biologics  Standards,
            NIE.  Their reviewer had (1) concerns regarding the need of individual hospi-
            .tals'for  specially trained staff since the referral laboratory will
            perform the more specialized tests, (2) specific questions  as  to
            reagent preparation and procedures, and (3) doubts  about  certain
            items in the supplies and equipment categories.  The  project  was
            considered to be very expensive.
            In sum, although the Committee recognized the need for more specialized
            laboratories, the educational component of this proposal  is  unimpressive



            REGIONAL MEDICAL PROGRAM                               RM  00013  7/70.1
            for WESTERN NEW YORK                 - 7 -


            and the budget is extremely large.  Consideration  was  given  to  a
            recommendation of Approval II (no additional funds recommended) to
            permit support of the project until funding  from  other  sources  could
            be obtained or until the activity  became  self-supporting,  but  it
            was decided finally that a technical site visit would be a more
            appropriate recommendation.
            Recommendation:  No action taken - need technical site visit.



            Project #17 - A Regional Program for the Prevention of Atherosclerotic
                           Disease


                       The Review Committee observed that this proposed project
                       seems to be hanging free in space and appears  not  to  be
            coordinated with any other activities.  The  only  backup  letter  is
            from the local Heart Association.  The reviewers were concerned
            that it is not tied in with already existing  programs  of  such  groups
            as the Diabetes Association, VNA, Public  Health  Nurses  or  activities
            of the State Health Department.  The  Ad  Hoc  Cardiovascular  Study
            Panel suggested that: (1)  expert  consultation  be  sought  relating
            to the feasibility of the project, (2)  consideration  be  given  to
            deleting electrophoresis on all initial examinations, and (3) a
            site visit be made. The  Panel  also  questioned  the  documentation
            of need for the project, whether a single dietician can perform all
            the duties outlined, and whether a greater precentage of the budget
            might not be assumed by the local or State Health Department.

            The Committee initially recommended that  the  application  be  returned
            for revision but on reconsideration decided  to  recommend  a  technical
            site visit.


            Recommendation: No action taken - need technical site visit.



            March 1970 Council Action:
            Council concurred with the recommendation of the Review Committee that
            the three projects receive a technical site visit


            Site Visit - May 18, 1970

            A report will be available at the Committee meeting.



                                                                         RMPS/GRB
                                                                         5/25/70





            REGIONAL MEDICAL PROGRAM
              for WESTERN NEW YORK                    8 -                 RM 00013 74/70.1




                                        HISTORY SUPPLEMENT



                                                                    Current   Year's
                                                                      Support or     Initiation
        Project                         Project Title                Status  -(DCOF     Date
         1            A Two-Way Communication Network                  $180,253         3-1-68
         2            Coronary Care Training                              168,152       3-1-68
         3&3S         Chronic Respiratory Disease Program                 655,379       3-1-69
                                   and
                      Respiratory Intensive Care Unit


         4            Immunofluorescence Service and Training             34,590        6-1-69

         5            Computer-tased Regional Poison Control
                        Program                                        Disapproved

         6            Pilot Study in Nuclear Medicine                  Terminated       3-1-69

         7            A Test of Two Continuing Medical Education
                        Techniques                                        17,920        6-1-69

         8            Planning and Education Program in Renal
                        Disease                                        Terminated       6-1-69

         9            Core                                                346,206         12-66

        10            Tumor Registry                                      46,294**      6-1-69

        11            Medical Genetics Clinic                          Disapproved-
                                                                       Inappropriate for
                                                                       RMP   Funding


        12            Provide via the Mass Media Information to
                        the Impoverished Residents of the Region       Disapproved

        13            Topical Chemotherapy Treatment for Precancerous
                        Lesions & Cancer of the Skin                      47,454        4-1-70

        14            Information Dissemination Service                   31,960        4-1-70

          Total of $1,528,208 includes $347,046 carryover monies
           $23,147 restricted pending Council Action  on  this  project  (see  Special  Action)

                                                                          RMPS/GRB
                                                                          5/25/70




                                                                       (A Privileged Coiiiiiiunic.,itioii'



                                     'SU@@IAIIY OF          @ili COINCLUSION OF
                                            JUNE 1970            COi)2,11'.UTEE


                                  WESTE Pi@( NEI,@T YORK REGI'Oj\,TA.I, l@IEDICAf, PP\O('@RA@l
                                                  P\m 00013  7/70.1


                              FOR CO'@'iSIDERATION BY Jtjf,'Y'  --970 AT)Vl,',OP,:.f (,'C)UN(@,I.L

               General.:   February   1970   Committee   recommended   that   the   three   projects
                           in  this  application  (along  with  the  Tuino-.r@   Registry   proposal
               which is presented as a Special Action) receive a technical. site visit.
               The  visit  was  made  on  May  18  and  the  report  of  tic  site  team   was   available
               to the Committee reviewers.  It was observed that the Western New York
               R14P is very well organized and has good regioiialization.  The Committee
               concluded  that  this  application.   which   reques@   $2,756,360   for   a   tliree-year
                rograni  period  should  be  partially  supported   at   the   reduced   amount   of
               @890)000.

               Project I[I.5 - A Tot@il. Regional Pro@,rarfi in Dialysis.

               L@t   Lqn@:  The  Committee   reviewers   were   -'mpresse(I   with   the   regionalization
                            evidenced by the project design and noted that the Region has
               the  five  components  n.(@,cessary  to  the  success  of  such  a   program,   i.e.,
               dialysis capability, satellite centers, an organ retrieval system, a tissue
               typing facility, and transplant competence,           Committee agreed with the
               technical  site   visitors   that   the   educational   component   for   nurses,   techni-
               ciaiis and other allied health personnel bad considerable merit but that
               the plan for physician training was unrealistically ambitious.  Further,
               the    physician.fellowship  program  falls  outside   the   purview   of   MIP   in   that
               it  is  designc  primarily  for  those  who  would  use  this   time   as   part   of
               their training for board certification.  The equipment needs of the project@
               were considered to be far less than indicated in the application.  The
               Committee experienced the same difficulty as the site visitor
                                                                                         s i.ii. determining
               the rationale for creating five dialysis centers,            Alth(@)-,Igli the  site  team
               thought that a more efficient way to h.-ii-.)dlc, the training program would be to
               establish only three centers, the Committee reviewers pre,'fcrreci a reduction
               to two.


               There was  some  sentiment  among  Committee  i-a@,iil:>c,.rs  that  perhaps  Western  New
               York had,i-aorc- important prol)le,-ns,@ than end-stage rc?7-iil  disease.  Ai.'I(l  there
                                               I
               was concern, as well, as to the wisdom of establishing dialysis centers
               in the absence of any llltiOD,al blueprint.        Parenthetically,    the    review    of
               this project emphasized the problems caused by the lack of guidelines to
               be used in evaluating the plc@t@ior,). of dialysis projects bein- presented
               for C@c)i-Eii-nittee consideration.


               The following minority report we-,;                  by one- iii-ei-n,ber.

                       cannot support a dialysis proc,i.-,,@i-i of this scope which:

                         is not integrated into                                  for
                         teririii-ial- renal, disease care,




               Ilegi.or).al Medical Program

                       is not educationally directed at anything but terminal
                       reri@-ii disease and lacks pediatric reiial. diagnostic and
                       preventive training,

                       is solely community hospital based and does not have
                       the direction of a major medical center,

                       has no provision for subsequent funding at end of year 3.

                  I suggest the Regioi-i has lost track of its real health priorities
                  for doctors' p27iorities."

            R e c ortp)i (3-ri cl a t i on :Despite the concerns voiced in the minority report, the
                               reported enthusiasm of the project personnel, the regionali-
            zati-c)n aspect of the program, and the quality of the project itself prompted
            the CoriT.Tiittee (with one dissenting vote) to recoiiijiiencl Approval I in a
            reduced amount of $250,000 for each of threc,.,years to provide for the
            establishment of dialysis centers at two hospital.,@;.  Specifical.13r:  th(--
            training courses  for  nurses,  technicians,  and  other  allied  health  personnel
            should be instituted is planned (but in two hospitals rather than five),,
            the training program for physicians shoi.il.d be less ambitious and limit
            itself to  familiarizing  participants  with  aspects  of  dialysis  necessary  for
            local physicians; tli-e personnel for training should be reduced to that
            necessary for only two centers; and the costs for all equipment, fellowships,
            laboratory tests and  reimbursements  to  hospitals  should  be  deleted  from  the
            operating budget.

            01 - $250,000                     02 - $250,000          03    $250,000

            Project -li@16 -ReRi-onal Coa2u].ation Referenc@e Labor  o

            @r      (1: It was not-led that even though very few regions    would be  able  to
                        have such a  central  laboratory  with  personnel  of  such  bxpertise,
            the project goals appear overly broad in that, in,  iclditi.oii  to  the  training
            of technicians from outlying hospitals, the project design calls for the
            performing of  complete  coagulation  studies  on  patients  from  throughout  the
            Regioi-i in order to have clinical material to tcacli medical students, techni-
            cians and other interested personnel.      Physician education would result only
            as a consequence of discussion and handling of referred cases         The Com-@nittee
            reva-c@,?ers igreed with the technical- site toiy[i. that although the goal of having
            a reference and stin,(Iardizin,@,, laboratory was an excellent one,  the  rest  of
            the teaching and service, aspects should be (]!-riiiiislied considerably.   A  more
            reasonable and adequate objective was seen to be Llic,. training of tecllillicial-i,@-,
            -froyri outlying hospitals to perform coagulatioii, tc,,st,,,,. It was thought that a
            greatly reduced budget-. would be sufficient for such an ej-.iclc@,ivo@-.




                          l@l E@,f YORK                                                   El@l uu@il.5   ///U. J@
                  Reg-ioi-itI. Medical Program

                             tiori:   Appi-c@-%7,-@l -1 for three years in a reduced amount with the
                                      following conditions:

                                      1.    Revision of f)rojec@t: goals as indicated above.

                                      2.    Provision with the third-year continuation request of
                                            a report on the. progress and impact of the project in
                                            the first two years of operation including a discussion
                                            of the appropriateness of the testing costs.

               01 - @60,000                             02 - $40,000                          03 - $40,000

               Project #17        A Regional. Propram for Atherosclerotic Di@sease.

               Critique:      The Conimittec,. revi.c-,@@,7ei--s agreed with the technical site visit teii-n
                              that any study of the type proposed should be directed more toward
               primary than secondary prevention,  that the -Viltie of performing electropho-r.-e@-is
               on all patients was questionable, that the follow,-up methodology was deficient,
               and   that   the   budget   was   excessive.   It   was   noted   that   the   project    bid    not
               received a review by a cardiovascular group at the Regional level.                           In genera
               the   feasibility   of   the   proposal   was   doubtful   and   the   value    of    the    dietary
               management and pl.aiiE-,, for physician education left iiiuct to be desired.

               Reco,,-rii'lic,nr a t i on :Noii--Appro-@,7al Ino Dr-a4.]:) funding recommended.

               Sal@'@lA@-ly OF RECO',,, IEI\TD.A,'110',,S:

                      PROJECT                                   01 Year             02 Year        03 Year        TOTAL

               W-1@5   Regional Proy-t.-oty[i in Dialysis       N,25C),OOO         $250,000,       $250,000      $750@000
               lp'16      Co@igijlation                            60,000             iO,000;         40,000      1-40,000
                          Laboratory
               Yr'17   Prevention of At:!-icroscl.erotic              ..O-               -0 --           -0           -O-
                          Discast--

                                                     TOTAL      $31C))OOO          $290,000        $290,000   $890,000










                                                                                                DR@IP  GP\.B
                                                                                                 7/13/70

















          @o@                                                               0                                                            0




                                                                            Privileged CbEiiiit-iiiicati@ol@1)
                                           SPECIA], ACI'ION


                          REGIONAL @'@EDICA.], PI"OGRAIL FOI', @@fl,"STI,',I"N Nill@w YOID@
                                               RY, 00013

                                                                            February 1970 Review Coiiiiii@i-tte-c-,
                                                                            March  1970   Council-
                                                                            @une 1970 Review Committee
               Project  #10   Western New York Tumor 11,
                                                         _Le -,@a
               When this project for a Tumor Registry was revie@ve'd        in   April-May   1969,
               it was considered by Committee and Council to be of          good  design   with
               well-docuniented procedures.  Approva  for a five-y@eai- period was
                                                       I
               recommended in the ay.,@ount  reqtiested@-laiid  the  project  was  funded  in
               June 1969.
               During  staff  review  of  the  progress   report   and   continuation   application
               for the Tumor Registry in mid-Feby-uary 1.970, it was discovered that
               the  three  key  people  who  submitted  the  proposal-  had  left   Roswell   Park
               and that  a  new  project  director  had  been  found  who,  with  the  help  of
               the Hospital Management Enoi.neering Program of tli(-,, Western New York
               Hospital  Association,  evaluated   the   project   design   and   concluded   that
               the  supporting  services  to  be  provided  by  such  an   automated   system
               must  be  revised.  Althou,,h  the  original  proposers   had   envisioned   the
               r6gistryis usefulness in epidemiological research, clinical-pathological-
               mortality correlations, and diagnostic/treatiiieiit method evaluation," and
               described  a   highly   innovative   and   unique,   technol-ogically-oriented
               registry,  an  abstract  form  designed  to  include   all   the   proposed   items
               is now deemed by the Region to be far too lengthy and complex, especially
               in  light  of  the  costs  involved  and  the  volume-  of  paperwork  which  would
               be  required.  Consequently,  the  primary  objective   of   the   project   has
               been  revised  to  become  i@proved  patient   care   through   improved   followup.
               A  shortened  abstract  form  of  41--items  has  been  adopted.  In   short,   the
               registry  which  is  now  being  implemented   is   significantly   different   from
               that  originally  proposed  and  approved  by   Review   Committee   and   Council.
               In view,  of  this  change  in  design,  the  02-year  award  for  this  project
               carried  a  restriction  on  use  of  half  the  funds   until   Review   Committee
               and  Council  recommend  acceptance  of  the  rev:@sed   plan.   The   Region   has
               been asked to submit information as to the degree and kind of difference
               between  the  original  and  the  revised  project,   the   acceptability   of
               the revised design to the Regional Advisory Group, and the relative
               priority of this project in the Regi.ori's overall plan.


                          February 1970 Review Committee.        Review  Ccff@inittee.  recommended
                          that  a  technical  site  visit  teiii,,  evaluate  the  revised  project
               as compared to that originally approved by Con,-@iittee and Council.
               Committee  noted  that  the  revised  tumor  registry  is  of  standard   design
               and provides information for follov7tlp and teaching purposes.         The
               revi.e@,7crs thought t@iat  since  the  project  plan  now  includes  fewer  facets
               than did the original proposal, the budget might be reduced.  A technical
               site  visit  ,!as  considered  necessary  to  evaluate  the   differences   between
                              I      -      -    @ t-                               p
               the original -.iO revised.               It wls ','Ll,@.0estc(.1 that th site  team
               a-Isc)                                of                            Institute    to
               the  Western     York            Medical

               P,c@comn,endati-on: Dc-f(,.r for tc@ctini-cal- site visit  and  return  to  Committee.






            Western Ne-v; Yorl@ PDIP              2-                    l@1,4 00013 7 /7 0
                                                                        Special Action


            Mar(,h 1-c@170 Coi-incil- Action

            Council agreed with the Revie@,2 Cor-irf@ii.ttee that action should be deferred
            pending the report of a technical site visit.  Staff was authorized to
            arrange for funding to maintain the prograDi until final action is taken.

            Site Visit - T.@ay 18, 1970

            A report will be avail-able at the Cow-,.iiittee meeting.




            I/  01    $72@137; 02    $46,294; 03    $50,438; 04    $54,464; 05    $58,726































                                                                         RMPS/GRB 5/27/70





                                                                (A Privileged Communication)


                                          SPECIB@ AG'!'-,'--ON


                            WESTEIUZ NEI-J YORK RECIONAI, MEDICAL --@)ROGr@l


                                             RM 00013





              General: A technical site visit team evaluated the revised tumor
                        registry proposal in comparison with the original design
              which was approved by April-May 1969 Committee and Council.



              Project #10 - Western New York Tumor     str

                         The Committee agreed with the technical site team
                         that although the revised tumor registry does not
              embody the innovative aspects of the original proposal, it does
              represent a more realistic registry program for this region At
              this time.  The early growth of the project was retarded by the
              revisions in personnel and design, but the reviewers saw the possibilities
              of the registry as a good vehicle for regionaliza.tion.  The active
              involvement of the Western New York Hospital Association and the plan
              for assumption of support by participating hospitals at the end of
              RMP funding were considered to be especially propitious.


              Recommendation:  Approval I - was recommended for continuation of the
                              cancer registry in the amount originally recommended
              by the National Advisory Council for the remainder of the period for
              which support has been committed.

              02 Year:  $46,294                            03 Year:  $50,438




                                                       GrJl 7/9/70








                                                             A PRIVILEGED COMMUNICATION
                                                                    RM 00013





                                 TECHNICAL SITE VISIT REPORT
                                      WESTERN NEW YORK


                                         May 18, 1970




                                Site Visitors & DRMP Staff



                      Victor Vertes, M.D. (Chairman)
                      Director, Division of Medicine
                      Mount Sinai Hospital of Cleveland
                      University Circle
                      Cleveland, Ohio   44106

                      Cyrus C. Erickson, M.D.
                      University of Tennessee
                      College of Medicine
                      62 South Dunlap
                      Memphis, Tennessee   38103

                      Leonard Scherlis, M.D.
                      Professor of Medicine
                      Chief, Department of Cardiology
                      University of Maryland Hospital
                      Baltimore, Maryland  20201

                      Abraham Ringel
                      Public Health Analyst
                      Operations Research and Systems Analysis Branch
                      Regional Medical Programs Service
                      5600 Fishers Lane
                      Rockville, Maryland   20852


                      Eileen Faatz
                      Public Health Advisot
                      Grants Review Branch
                      Regional Medical Programs Service
                      5600 Fishers Lane
                      Rockville, Maryland  20852


                      Individual representatives of the WNYRMP are listed in the
                      text of the report.






           Western tew York              - 2                  RM 00013
           PROJECT #10 - Western  New  York Tumor Registry

           Pat Shine                       Regional  Medical  Program
           L. Donald Meyers                Regional  Medical  Program
           Leonard Kaye                    Regional  Medical  Program
           Elsa Kellberg                   Regional  Medical  Program
           Marion Sumner                   Regional   Medical Program
           John R.F. Ingall, MiD.          Regional  Medical  Program
           Jc,hn C. Patterson, M.D.        Regional  Medical  Program
           Dolores Celest                  Tumor Registry
           Ray Caputo                      W.N.Y. Hospital Association
           Bob Keefe                       W.N.Y. Hospital  Association

           The original tumor registry proposal was approved  by  May  1969  Council
           and was funded in June 1969. The  objectives  and  methodology  of  this
           project, however, were changed in midstream because of changing    personnel,
           the three key people who developed the  registry  having  left  Roswell Park.
           Dr. Patterson, the 'new project director, with the  assistance  of  the Hospital
           Management Engineering Program of the Western New York Hospital      Association,
           evaluated the original design and concluded that  it  should  be  revised.

           In reviewing the request for continuation of the tumor    registry  into
           the 02 year, staff decided that the Review  Committee  and  Council  should
           approve the revised plan.  February/March  1970  Committee  and  Council
           recommended that a technical site visit  team  evaluate  the  difference
           between the original and revised projects.  The revised program is
           less innovative and sophisticated than the  original  but  more  feasible
           and acceptable to the participating hospitals.  In  fact,  one  of  the
           reasons for revising the project was  that  hospital  administrators  and
           staff physicians looked askance at  the  expenditures  which  participating
           hospitals would incur under the original design.

           Revisions it, personnel and design retarded the early  growth  of  the  registry,
           and the system did not really get under  operation  until  January  1970.
           Fourteen hospitals now  are  par'ticipating in the tumor  registry,  and  six
           additional hospitals are expected to join the project soon.'To date, only
           onehospital has refused to cooperate.    It was the feeling of  the  site
           visitors that the revised project has more strength than the original in
           that it is more realistic for this Region  at  this  time.  Although  there
           is nothing particularly novel about the present program,  it  does  have  a
           cancer hospital as its fulcrum (with which the  WNYRMP  has  apparent  good
           relationships), and it holds the possibility  of  gaining  the  cooperation
           of a number of outlying hospitals. Dr.  Patterson  explained  to  the  site
           team that project personnel consulted with the  New  York  registry  which
           they found will provide them with  only  death  information.  Even  though
           the project is off to a slow start and programming may have been premature,
           the visitors saw in the registry the  potential  for  cooperative  efforts
           among several hospitals in developing a standard service and educationally-
           oriented tumor registry. The  development  of  this  cooperative  system
           was viewed as increasing the opportunities  for  physician  education  in
           cancer and the development of referral patterns in specialized facilities.
           Of extreme importance is the fact that the  engineering  group  of  the
           Western New York Hospital Association  is  participating  in  the  implementation
           of the registry.  At the end of RNP support it is planned that the partici-
           pating hospitals themselves ultimately will assume the costs of operation.
           The revised budget total is identical to that  requested  and  awarded  for





               Western New York
                Site Visit                   - 3                       RM 00013



               the original proposal, and the visitors considered the budget well
               within reasonable bounds.


               Recommendation

               In summary, the revised cancer registry does not have the unique character
               of the original proposal, but the site team viewed the changes as for
               the better.  The recommendation is for continuation of the project in
               the amount originally recommended by the National Advisory  Council  for
               the remainder of the period for which support has been  committed:  i.e.,
               the rest of the 02 year and the 03 year ($46,294 and $50,438).  Although
               some members of the site team suggested that further programming be
               halted until the project has accumulated much more data and  tested  the
               existing programs, others felt that such a limitation was unduly
               prohibitive.


               PROJECT #15 - A Total Regional Program in Dialysis

               Dr. Albert D. Menno            Meyer Hospital, Deaconess Hospital
               Dr. John M. Hodson             Deaconess Hospital
               Dr. Roland Anthone             Buffalo  General Hospital
               Dr. Sidney Anthone             Buffalo General Hospital
               Marion Sumner                  Western New York RMP
               Dr. John R.F. Ingall           Western New York RMP, Director
               Dr. J.D. Lasher                Hamot Hospital
               Mr. V. Sirak, Jr.              Hamot Hospital
               Dr. G.P. Murphy                Roswell Park Memorial Institute

               This proposal received generally favorable reviews from the Kidney Disease
               Program, the Review Committee, and the National Advisory Council.  There
               were concerns, primarily revolving around the wisdom of establishing
               dialysis centers in five hospitals, that prompted Committee  and  Council
               to recommend a technical site visit for this project.

               The site team was most impressed with the regionalization  evidenced  in
               the project design and with the fact that there are in this region tissue
               typing facilities and the beginnings of a kidney bank  which  encompasses
               Western New York and parts of Canada.  The physicians and nurses involved
               in the proposed project are well trained and well motivated.  The project
               representatives explained that the New York Kidney Institute  at  Albany
               is not involved in this program and the goal of this project is  not  to
               establish an alternate institute in the Western part of  the  State.  The
               Albany program is mainly extramural and developed primarily in  New  York
               Ci'ty.  The group was not aware of the approved but unfunded dialysis
               training program in Central New York.

               A detailed analysis of the teaching program convinced the team that
               there is considerable merit to the educational component for nurses,
               technicians, and other allied health personnel.  Plans call for training




          Western New York
             Site Visit                   - 4 -                    RM 00013


          t@iese people at the rate of approximately 100 per year in six-week
          courses.  There was, however, considerable  concern  about  the  physician
          training component.   The goals appear overly ambitious 'in that  at  the
          end of a six-week education period it  is  expected  thatthe  20  physicians
          trained each year will be capable  of  establishing  dialysis  units  in
          their hospitals and handling  the  patients  from  conservative  therapy
          through dialysis,  transplantation,  and  possible  rejection.  A  physician
          would have to leave his practice for six  weeks  in  order  to  participate
          in the program.  The project staff anticipates  that  20  such  physicians
          would be available each year. The intent  of  the  program  for  nurses  and
          physicians is to concentrate on training  people  from  the  Region,  although
          the courses will be open to participants  from  other  areas  and  Canada.
          The costs for Canadian trainees will not be  charged  to  the  RNP  grant.
          The number of people who will need to be trained ultimately  is  a  question
          the Region has not yet addressed, although it is expected  that  a  number
          of the nurses will drop out because of marriage, pregnancy, etc  '   There
          are, in  addition,  plans for providing six fellowships for those physicians
          who whish to  remain  for a several-month period.  These fellowships would be
          primarily for  those  who would use this time as part of  their  training
          for board certification, and the site team thought this  training  did  not
          fall within the purview of RMP.

          The visitors questioned the need for equipment and  wondered  why  RMP
          would  pur-chase apparatus that the hospitals  should  have  already.  Project
          staff explained that the intent was that each hospital  would  have  one
          kidney machine to be used solely for  teaching  purposes.  Further,  since
          patients being trained for the home would have to buy their own equipment,
          the site team saw no reason why training could not be  achieved  on  the
          machines to be used for a given patient in the home.    In addition,  it
          was agreed that the costs for laboratory tests,  blood,  and  reimbursement
          to hospitals for beds could be eliminated from the budget  if  the  teaching
          program would concentrate on those patients with  Blue  Cross,  Medicaid,
          or other tliird-party coverage.

          Project staff failed to convince the site team of  the  desirability  of
          having five dialysis centers, expecially since the didactic training
          would occur in only one institution (using personnel from all participating
          hospitals) and the experiential phases would rotate among the institutions.
          The visitors thought that a more efficient way of  handling  the  training
          program would be to establish only three centers.  This number would
          still provide the trainees with a varied background  in  dealing  with
          different equipment and techniques.

          Recommendation

          The site visitors recommended approval of the program in  a  reduced  amount
          of $250,000 for each of three years to provide for  the  establishment  of
          dialysis centers at three hospitals.

          Specifically, they believed the training courses  for  nurses,  technicians,
          and other allied health personnel are well-designed and should be instituted
          as planned (but in three hospitals rather than five).    It was felt  that
          the training program for physicians should be less  ambitious  and  limit
          itself to familiarizing participants with aspects  of  dialysis  necessary
          for local physicians.   It was considered that the personnel  for  training
          is essential, but should be reduced to that necessary  for  three  centers.





              Western New York
                  Site Visit                                            RM 00013
                Further, the costs for all equipment, fellowships, laboratory tests
                and reimbursements to hospitals should be deleted from the budget.


                PROJECT #16 - e ional  Coa  ulation  Reference  Laborator
                Lvis L. Mosovich, M.D.          Department Pediatrics - Children's Hospital
                Norman B. Courey, M.D.          Gynecology  &  Obstetrics   Deaconess Hospital
                Marion St Lmner                 Regional Medical Program     Western New York
                Julian Aribrus, M.D.            Roswell Park Memorial Institute
                Clara Ambrus, M.D.              Roswell Park Memorial Institute
                Irwin B. Mink, M.D.             Roswell Park Memorial Insititute
                Herbert E. Joyce, M.D.          Regional  Advisory  Group
                The February/March review bodies  recommended  that  this  project  receive
                a technical site visit, primarily because of the unimpressive educational
                component and the extremely large budget.
                Ti'ie site visitors found that  the  expertise  of  the  individuals  involved
                with this project was exceptional and that their knowledge of coagulation
                and the existing laboratory facilities were most impressive.  The tests
                described in the proposal are  ongoing  activities.  The  site  team  felt,
                however, that the goals of the project are too broad.  Besides training
                technicians from outlying hospitals,  the  project  personnel  intend  to
                perform complete coagulation studies  on  patients  from  throughout  the
                Region in order to have clinical  material  to  teach  medical  students,
                technicians, and other interested personnel.  To accomplish this, the
                Director is applying for the complete  furnishing  of  a  new  laboratory
                as well as funding for 13 technicians, a senior biochemist, and a senior
                physician. The site team thought that  although  the  goal  of  having  a
                reference and standardizing laboratory was an excellent one, the rest
                of the teaching and service  aspects  should  be  diminished  considerably.
                It was the visitors' opinion that training technicians from outlying hospitals
                to be able to return to their own institutions  and  perform  some  of  the
                coagulation tests was a more reasonable and adequate objective.  It was
                thought that perhaps one-fifth of the budget would be necessary for this
                type of endeavor.

                Recommendation
                Approval of $60,000 forthe first year and  $40,000  for  the  second  and
                third years, with revision of  project goals as suggested above.


                PROJECT #17 - A ReRional Program for Atherosclerotic Disease
                W.E. Mosher, M.D.                Erie  County Health Department, Commissioner
                Millicent Toppin                 Erie  County Laboratory
                Thomas Tiffany                   Erie  County Laboratory
                Wallace T. Williams              Dietetics  & Nutrition, State
                                                   University College
                George Johnson                   Erie  County Laboratory




         Western New York
            Site Visit                       - 6 -                   RM 00013


         Christine Falkowski               Erie County Laboratory
         Leonard Kaye                      Western New York RMP
                                           Erie  County  Laboratory  -  E.J.  Meyers
         Leila Edwards
                                            Memorial Hospital Division
         Michel A. Ibrahim                 Erie  County  Department  of  Health  and
                                            Department of Preventive Medicine
         Ruth Kocher                       NYS Health Department, Buffalo
         Max E. Chilcote                   Erie County Laboratory, Department of
                                            Chemistry, SUNYAB
         Marion Sumner                     Western New York RNP
         John R.F. Ingall,   M.D.          Western New York RNP, Director
         Robert Kohn, M.D.                 SUNYAB

         When this proposal went through the February/March 1970 Review Cycle
         there were many general questions as to the feasibility of the project,
         the coordination of this activity  with  others  in  the  Area,  as  well  as  more
         specific  procedural  concerns.  A  technical  site  visit  was   recommended.

         The visitors found  that  the  positive  aspects  of  this  program  included:
         (1) the interest and ability of project personnel to establish the
         laboratory and perform  the  analysis  with  quality  control,  and  (2)  more
         involvement of  other  agencies,  such  as  the  State  Health  Department,
         than had been expected.  In addition, there is presently no  aci ity
         in Western New York  which  handles  such  analyses  on  a  routine  basis.

         The project representatives  described  the  goal  of  the  program  as  being
         the  provision  of  prompt  prophylactic  measures  for  atherosclerosis,  yet
         the group which they will be treating has already had evidence of
         atherosclerotic disease.  The value of this  program was questioned seriously
         since the visitors felt that  this  type  of  study  should  not  be  directed
         toward the secondary group but should be looking more to primary prevention.
         There is an exclusion of patients who would benefit by primary prevention
         and, therefore, by  the  dietary  control.  No  attempt  will  be  made  to  deter-
         mine other high-risk  factors  in  patients,  such  as  documentation  of  the
         presence of hypertension,obesity, etc.  The visitors further questioned
         the  desirability  of  performing  electrophoresis  on  patients  with  normal
         cholesterols and normal total triglyercides, but the project representatives
         offered no justifiable explanation.

         Another concern of the visitors revolved around the follow-up and
         evaluation scheme - the  methods  used  to  define  the  success  of  the  project.
         The project will attempt to answer such questions as whether the patients
         follow the prescribed therapy and whether the prescriptions do, in fact,
         reduce lipids.  But the problem of whether the therapy prevents atherosclerotic
         disease will not be addressed.  The team considered this a major deficiency
         in the project design.

         The budget was  considered  excessive  to  the  goal  of  establishing  a  referral
         laboratory.  Furthermore, patients who are referred to the laboratory
         by their physicians but who do not fit into the defined high-risk group
         will be charged $20.00 per determination.  This fee will not be applied to the






               Western New York
                 Site Visit                        - 7 -                   RM 00013

               cost of the project but, rather, will go into  a  special  research  fund  of
               the laboratory.


               Recommendation
               The suspicion of the visitors that this project had received no local
               review by a group knowledgeable  in  cardiovascular  disease  was  confirmed.
               Although the team felt there was a definite  need for a reference laboratory,
               the feasibility of the current proposal was in doubt, and the value of
               the dietary management and plans for physician  education  left  much  to  be
               desired.  It was the visitors' consensus that this project should be
               disapproved and returned to the Region for referral to a local heartcr research
               group for funding or for revision and reorientation of the program to
               emphasize multiple risk factors  and  concentration  on  primary  prevention,


               Conclusions of  Site  Team                  Recommendation
               .Project # and Title                   01 Year        02 Year       03   Year
               #10 Western New York*                  $46,294        $50,438          -
                   Tumor Registry
               #15 A Total Regional                  $250,000       $250,000        $250,000
                   Program in Dialysis

               #16 Regional   Coagulation
                   Reference   Laboratory             $60,000        $40,000         $40,000

               #17 Regional  Program  for
                   the Prevention of
                   Atherosclerotic Disease         Disapproval        -                -


               Total                                 $356,294       $340,438        $290,000



               *Continuation of 02 and 03 years recommended.














                                                                                    GR-B-6/23/70

















          @10                                                              0                                                              0






                                ,REGIONAL-MEDICAL PROGRAMS SERVICE
                     SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION
                                   (A Privileged Communication)


           WESTERN PENNSYLVANIA                                        RM 00041  7/70.1
           REGIONAL MEDICAL PROGRAM                                    June 1970 Review
           M-240 Scaife Hall                                            Committee
           3550 Terrace Street
           Pittsburgh, Pennsylvania   15213

           Program Coordinator:  Francis  S.  Cheever,  M.D.

           Requested
           Program
           Period          lst Year    2nd Year     3rd Year      4th Year    5th Year  Total
           Direct Costs     $43,911    $44,820       $46,995       $4,800     3,900    $144,426
           Indirect Costs    11,062     11,474        12,030        1,229        998     36,793

                TOTAL       $54,973    $56,294       $59,025       $6,029     $4,898   $181,219

           History:  The   planning grant was funded January 1,  1967  in the amount  of
                     $271,736  (D.C.).  During  the  firstyear  some  organizational
           difficulties were experienced.  This resulted in an extension of the grant,
           without additional funds, for 90 days,  to  March  31,  1968.  A  Program
           Director was named during this  period  and  assumed  full-time  responsibility
           June 1, 1968. The Regional Advisory  Group  was  expanded  and  reorganized  to
           include representatives of hospitals as well as county medical societies.
           The second year planning continuation grant was awarded effective
           April 1, 1968 in the direct cost amount of $260,484.  With a car.ryover
           balance of $212,823, the new  funding  amounted  to  $113,942.


           A supplemental planning grant award in the amount of $93,750 (D.C.) was
           authorized by Council in January 1969 for Core activities in order to
           provide continuity to the program while the  region  awaited  approval  of  its
           operational status.
           A site visit was made on February 24-25, 1969 to evaluate the region's
           request for operational status.  The site team examined how the program had
           evolved, the extent of involvement of all  health  interests,  how  the  region
           determines priorities, relationship between the grantee institution and the
           Rt4P, roles of the RAG and committees and future plans.
           Council concurred with the site visit team and Com   mittee's recommendation of
           approval of five projects and Core.  One  project  was  returned  for  revision
           with advice to re-submit a request  for  the  RMP-relevant  portion  only.  The
           WP/RMP received its first operational grant award  in  the  total  amount  of
           $1,157,896 ($934,041 D.C.) effective July 1, 1969.  Project #4 to provide




                                                    -2-                 RM  00041  7/70.1
            i4estern Pennsylvania RMP

            training for hospital Emergency Resuscitation Teams, was supplementally
            awarded ($88,000 D.C.) for an eighteen-month  period  after  issuante,of  the
            N.A.C. policy for projects of this kind.
            Project #8 - Laurel Mountain Home  Health  Aide  Training  and  Demonstration
            Project - was recommended for disapproval  by  the  November/  December  1969
            reviewing bodies.  After evaluating comments of the N.A.C., the local Advisory
            Committee for the three-county Area involved and the R.A.C. of WP/RMP reaffirmed
            their belief that the project is significant to the outreach of the WP/RMP, and
            asked for reconsideration for approval for implementation from unexpended funds.
            The N.A.C. recommended approval, with no additional funds, of support for such
            training costs.
            The present level of support for the region for Core and seven projects is
            $1,022,041 (direct costs).  The operational activities are as follows:
                   Project                                                  Funding Level (D.Cj
                   Core                                                          $475,041
                   #1  -Postgraduate Faculty of Medicine                          34,000
                   #2  -Hypertension Management                                   90,000
                   #3  -Regional Program for Nurses in Heart, Cancer,
                        Stroke                                                    160,ooo
                   #4  -Emergency Resuscitation Team Project                      88,000 (18 mos.)
                   #6  -Training of Nursing Home Personnel                        125,000
                   #7  -RHP Library System                                        50,000
                   #8  -Laurel Mountain Home Health Aide Project          No Additional Funds
                                                           TOTAL               $1,022,041


            Present Application:
            GENERAL: After more than half-way  through  the  first  year  of  operational
            activities, the region feels that planning efforts are showing satisfactory
            results.  A first Annual Planning Conference was held in the fall of 1969.
            This application reflects the priority expressed then.
            The Comminity Involvement Committee has completed the organization of nine
            Area Advisory Groups.  This Committee has stimulated interest in development
            of health care programs for the poor and there  is  agreement  that  the  RMP
            should focus on methods of improving the system of primary medical care for
            this segment of the population.




            Western Pennsylvania RMP            -3-              RM 00041 7/70.1

            The Grants Review Cowmi.ttee membership has been broadened for a wider community
            representation in the Grant Review process, and in addition, the Committee is
            working with WP/RMP staff on project evaluation.
                                                                               Ist Year
                                                                                $43,911
            Project #9 - TraininR of Cancer Chemotherapists for the Community Hospital
                        This project proposes to develop a cadre of physicians who are
            interested and competent in the advancing field of chemotherapy.  The appli-
            cation requests support for a preceptorship training program in cancer
            chemotherapy for practicing physicians in Western Pennsylvania.  These
            physicians will serve as important members of cancer committees in hospitals
            throughout the region in line with the region's four highest priority interests.
            These Chemotherapiate, in cooperation with other members of their medical staffs,
            will provide cancer p&tientB with a balanced treatment program including cancer
            chemotherapy, radiation therapy, surgery, radioisotope therapy, etc.  in addition
            to beginning the organization of a cancer treatment system for the region, the
            project is designed to make available the benefits of modern cancer chemotherapy
            to patients throuer,@out Western Pennsylvania.
            The program emerged as a result of planning of the Cancer Committee of the
            Western Pennsylvania Regional Medical Program and its Task Forces on 1) tumor
            clinics and tumor registries; 2) angiography; 3) chemotherapy; 4) radiation
            therapy; 5) community education and motivation in oncology; 6) continuing
            postgraduate education in oncology; 7) nursing and paramedical manpower; and
            8) screening and casefinding,
            The priorities for a Regional Cancer Program were developed by these Task Forces,
            discussed and modified by the Cancer Committee, and approved by the Regional
            Medical Program Advisory Committee (R.A.G.).  Their objectives include 1) support
            of multi-disciplinary efforts in cancer management by hospital staffs throughout
            the Region; 2) establishment of a network to link these multi-disciplinary
            groups to each other and to teaching hospitals in Western Pennsylvania; 3) cancer
            registries as needed; 4) postgraduate education efforts for health professionals
            and 5) an educational. program to motivate the public to seek earlier care for
            symptoms suggesting cancer.
            The region's Cancer Program will be augmented by a feasibility study for
            which approval has been requested from the Division Staff.  This study will be
            initiated by a nurse specialist in oncology in cooperation with the Pennsylvania
            Cancer Society.  Initial programs will be carried out in cooperation with local
            units of the Cancer Society, but will also provide professional liaison with
            various lay groups simulated by the Society, such as the Lost Chord Club, the
            Reach for Recovery Group, etc.
            The WPIRMP has developed a close relationship with the Hospital Utilization
            Project (HIJP), which provides participating hospitals with a ready-made
            registry of all cancer patients admitted.  The registry in its present form
            provides only minimal information about therapy (surgical procedures primarily).




          western  Pennsylvania                  -4-              RM 00041 7/70.1


          The project will also rela-te to the State Health Department which  provides
          partial support of cancer registries in 31 hospitals and includes 68%  of  the
          hospital beds in Western Pennsylvania. By correlating the  efforts  of  all
          three agencies (WP/RMP, HUP, and the State Health Department), it  is  hoped
          that the needs for data about cancer programs by local medical staffs  can  be
          met. '

          The Cancer Committees in the various hospitals will consist of at least the
          hospital radiologist, pathologist and the community  chemotherapist  trained
          in the present program.  In addition, a surgeon with special interest in
          cancer and other appropriate members will be chosen by the hospital's
          medical staff to join this committee.
          One physician member of the Chemotherapy Committee (Dr. John B.  Hill)  will
          give ten hours per week (1/4 time) as Project Director supervising the program
          attending to the administrative details, etc.  He will be assisted by a
          secretary (1/3 time). The Project Director will work from his  office  at  the
          Vestern Pennsylvania Hospital which will act as the fiscal agent for the program.
          An oncologist will be added to the WP/RMP Core staff to work  closely  with
          Dr. Hill and the University Health Center oncology group. He  will  assist  in
          the full development of the Community Hospital Cancer Committees as  a  part
          of his major role, and will assist Dr. Hill in implementing program evaluation.
          Four to six students will be accepted in each six-month period over three years,
          Selections will be based on potential for service, taking  into  consideration
          training, age, health, hospital staff appointments, etc.  All will be physicians
          in practice, including both general and specialty practices.
          The faculty for the program will consist of 11 Pittsburgh physicians  who  are
          fully trained members of the Pittsburgh  Chemotherapy  Committee.  Curricula
          Vitae are attached to the application.
          It is the intent of the training program to develop in the 36 participating
          physicians the knowledge and skills adequate to permit them to initiate certain
          kinds of commonly needed chemotherapy. They will take  responsibility  for  the
          continuation of more complex or unusual treatments which are initiated in a
          referral center. Participating physicians will be encouraged  to  refer  appro-
          priate patients to treatment centers for new or highly complex forms of chemo-
          therapy requiring special skills or facilities. They will  also  be  encouraged
          to work with other members of their hospital staffs to provide  a  balanced
          cancer care  program.

          During the final two months of the course, students will be  encouraged  to
          undertake the treatment of selected patients in their home areas,  and  will
          discuss these patients' problems with their preceptors.  Refresher courses will
          be offered each six months in the form of another day and a  half  course.  For
          one and a half years following the initial six months training  period  each
          community chemotherapist will report regularly on his  chemotherapy  practice.
          In addition he will make quarterly reports describing the progress  of  all
          patients. The staff oncologist and/or Dr. Hill will  visit  the  chemotherapist
          in his coamnity to provide on site consultation and guidance.
          Second Year:  $44,820                        Third Year: $46,995
          Fourth Year: $  4,800                        Fifth Year: $ 3,900




                                                       western Pennsylvania kul vuuz-@i ///V.i








         FF OBSERVATIO'@N

       Attention is drawn to the internal r6-View,process of WP/RMP and specifically
       page 31, Section 6, which indicates that in 6Valuating the project, the
       R.A.G. made certain reductions in the budget.  This accounts for the
       difference in the amounts on pages 8 and 9, which reflect reduction in
       the equipment and space rental requests.





































                                                                    GRB 5/6/70



                                                                      K I  LiV L It: I-, U 1.1 UIJLLIIELK@LIL J- -11




                                      SUMMARY OF'REVIEI%T AND CONCLUSION     OF
                                           JUNE ]@970 P,1!7VIEl@@ CO@il@ITI@'l",L",


                                WEST)3RN PENNSYLVANIA REGIONAL MEDICAL          PROGRAM
                                                  RM 00041 7/70.1


                              FOR CONSIDERATION BY JULY 1970 ADVISORY           COUNCIL


              General:  The  Committee  approved   this   application,   requesting   funds   for   one
                         new project.  This is the region's first effort at establishing
              a region-wide cancer program.  It is a cooperative endeavor with local Units
              of  the  Cancer  Society,  various  lay  groups,  such  as  the  Lost  Chord  Club,   The
              Reach for Recovery Group, etc.  It will ilso,relat@e to the State Ile@iltl-i Depart-
              merit, as v7c-11 as the Ilospital. Utili?.ation Project, which provides particil)atin-
              hospitals,uith a ready-made registry of all cancer patients admitted.
              Project lr'9 - Traini.n5z of  Cancer  ChE@iiiathera  ists  for  the  Community  Hospital.
              @ri@).       The proposal was found to be quite impressive and one          of the best
                          written of 4-t8 kind.  It indicates a great deal of sophistication
              in  its  development  and  is  thoughtful  and  thorough  in  spelling   out   its   details.
              The outreach aspects are excellent.
              The goals of the project are capable of mc@asuremc@jit and i,n accordance ivit
              P,MP goals.  1rie reviewers noted excellent documentation as to numbers of
              patients who will, be iffected by this training activity.
              V.Tiil6  the  evaluation  plan  i.s  appropriate,  project  staff  identified  for   this
              purpose was not considered to be very strong.  It was noted, however, that
              there is apparently a good evaluation backup on the WP/PI-IP staff.  The
              suggestion was made that the applicant should be quc-rri.ed to make cortairr
              the evaluation they propose can be carried out within the requested financial
              allotment.

              The  overall  plan  seems  sound  except  for  a  possible  problem   with   trainees   whose
              practices mi.ght i.nL(@rfei.-e wi.tli their training  scb(,idiil.es.  It  would  appear  that
              a  busy  practitioners  ability  to  spend  one  day  a  weel@  would  be  difficult   to
              accomplish.

              The reviewers also  raised  the  question  of  the  oncoloE,,i,st'.  who  is  being  recruite
              for the WP/PdIP Core Staff.  They wondered if his salary would be partially
              financed otherwise.


              Recommendation:  Approval I

                            First Y ar                  Second Year                   Third Year
                            @43)93.1                    @44,820                       @46,995




            WE,i'J'Ef@1'4 PLI.,,TNSYLVAN'!A Rli-@D                       iui ooo/@i 7/70.1





                                        SIRI-%L4PY OF



                               01-Year           2 @,Y r         03-Y6ar           To ta 1.
            L@O e@C t
            #9                 $43,911          $44,820          $46,995          $135,726



                 Total         $43,911         $44,820           $46,995         $135,726


















                                                                 R).4PS/ORB/7/13/70





















           a                                                              a                                                              a









                                        REGIONAL MEDICAL PROGRAMS SERVICE
                         "I!I!N,Al@Y OF A St)PPLEM.FNTAI, OPT-,'RAI'TONAT, GRANT APPI,TCA'! 10@l
                                      (A Privileged (,omniiinicatioii)

                         t@l,,(;I,ONAL, MEDFCAL PROCRAL                             0003,-, i-/-i'O.-i
             I I 0 I:;-) S i@ t-f i @('OTISi n Avenue                           Jt)ne 1970 Review Committee
             @lilw,,tiil@ce,            5"1202

                      (coordinator:      John S. Hirscliboeck, M.D.

             l@c@qtiested               Ist   Yr.         2nd    Yr.        3rd    Yr.          TOTAI,

             I)i.rect (,osti             $132,915           $125,215          $125,215          *383,345
             Indirect Costs.               20,330             20,330            20,330            60,990



                  ']'O'I'AI,S            $153,245           $145,545        $1145,51@5          $444,335

             History:     See   7/70.2    for    regional    history of    this    application.)     This
                         application   was   originally   submitted   during   July   1969   as    a    major
                     manpower    development    project    with    eleven    subcomponents.     The     original
             program Would establisl) a multidisciplinary and interinstitutional. approach
             Lo the tr,)i.ning of health science personnel through the, development of q
             Department of Health M@inpower and Contii)uing Education at the Marquette School
                Me(licin(, - with ten separate training components.   However, during October
             1969,  t[it-   Region   requested   that   the   application   be   withdrawn   from   the   review
             process.   This   request   was   made    because    of    anticipated    fiscal    developments
             -)t  @lar(Itiette.  I'lie  school,  which  was   in   serious   financial   trouLle   when   the
             @ipptication   was   originally   submitted,    is    now    receiving    essential    financial
             Support   for   its   operation   from   the   State   of   Wisconsin.   It   was   believed   that
             ,an  endeavor  of   this   magnitude   could   not   have   been   undertaken   until   the
             fi-nin(-,i;)l structure of the school became more solid.

             'I'lierefore, ttie Region is now requesting that the original application be
             restoi-e(i  to  the  review  system  in  a   modified   form   and   with   redt.iced   budgets.
             11, lie modifications are defined in a letter from the Program Coordinator,
             dated February 12,  1970, which states that seven of the twelve original
             components were deleted (C,D,E,F,G,H, and J), and components A,B,I,and K
             were   retained   @ts   integral   parts   of   the   application.    The    revised    application
             now  consists   of   the   February   12,   1970   letter   and   the   four   components
             mentioned above.   (,Subcomponents A,B,I,and K are separated by pink
             papers  in tlii.s application.)   Direct costs only are noted.

                                                                                                    Requested
                                                                                                    F'i.rst Year
             I)roject #I(SA - Department of Health Manpower and Continuing                          $50,765
                               Education at Marguette'School of Medicine.
             'I'he original request for Component A, for the first year, was
             $130,400.   This   has   now   been    reduced    to    $50,765.    Project    ComponentA
             of   the   Health   Manpower@Development    Project    calls    for    the    establish-
             ment   of   a   Department   of   Health   Manpower   and   Continuing   Education    at the
             Marquette School of Medicine.   This department will be the kev to the





                   Regional @ledical 11'rogr@im     - 2 -            Rl,l 00037 7/7(J.1

                                                                                   Requested
        development of continuing education in the Medical Center which            First Year
        is being planned to be, among other things, the    'locus for inter-
        professional  and  interinstitutional  continuing   education   coordination
        in the southeastern Wisconsin area.     The project provides a base
        til)oti which the entire continuing education program can be developed.
        Since it relates to the Medical Center and the associated institutions,
        it should provide the basis for the coordination of teaching efforts
        not only for medicine but of the  various  members  of  the  team  effort  in
        medical and health practice in the major teaching hospitals in this
        ni-e.i.  Its objectives should be therefore:
           1.  To  develop  and  coordinate  interdisciplinary  continuing  education
               for medical and health professionals in the Medical Center facilities.
           2.  To provide the meeting  place  and  communication  for  the  coordination
               and develoliment of continuing  education  of  institutions  and  pro-
               fessional organizations outside the Medical Center.
           3.  To  develop  and  maintain  interprofessional  and  interinstitutional
               evaluation of continuing education both within and outside the
               Medical Center.

           4.  To act as a resource  and  consultation  staff  to  professional  and
               institutional  organizations  desiring  to  establish   interdisciplinary
               and interinstitutional continuing education programs.

        ,@itice the medical, center is not expected to be fully developed for several
        vears, and the coordination of continuing education will be an ongoing task,
        it is proposed that staffing of the Department of Continuing Education begin
        on a liqlf-ri.ii:e      including an associate dean in medicine, an Associate
        director !-,ji: ni-irsir,-, and an associate director for allied health, pILis a
        f@ill-tinie secretary.  80'4 of the budget request is for personnel.

        Second Year:   @e46,965                   Third Year:    $46,965
        Llro.ject ',@ISB - Nephrology. The original request for Component B           $21*100
                        was for $26,959 for  the  first  year.  This  has  now  been
        reduced to $21,100.    Other than a total of $1,300 for supplies and
        travel, the remaining support requested is for personnel.
        A            !)iock of clinical  experience  will  be  provided  internists,
        surgeons,  gynecologists,  urologists,  and  general  practitioners,   geared
        to@)ard: 1) improving  their  ability  to  interpret  electrolyte  and  acid-
        base measurements, and translate this information into appropriate plans
        of therapy; and 2) improving  skills  in  early  detection  of  kidney  disease,
        rising simple routines available at all hospitals.      Physicians who complete
        training will be invited  to  return  and  attend  weekly  teaching  conferences
        of the Renal Service and other pertinent meetings.       They may also elect to
        return at intervals, in order to add to their technical skills or gain more
        information ibout specific problems they encounter.       It is hoped that 12
        i)ltysicians will receive this training.





                                      i@@giotiil ',Iedical Prograii)                      - 3                                R@l 00
                                                                                                                                             7/-O.l


                                                                                                                                           'Re ci, Liested
                                                                                                                                           First  Yeir
                                                    ,!ill  be  offered  one  aiontli  of  sLi,-.)ci-\@i,,@ed
                      c t ill i cc, I t@ r@l i IIiig i ii the c@i re of patients wit l-I d iSt Lirbaiice,,, i ii
                      f't@iict  c,lecL.,-ol@,te  and  acid-base  metabolism.                      A  detailed  curriculum
                      is            development.             illins  call  for  12  nurses  to  be  trained.                           @'eam
                      LL,,iciiitig will-  be  utilized  and  coordinated  physiciiii-niirse  care
                      is         intended.

                      !2@ecoii(i     Year:   $21,100                             Third  Year:           $21,1,00
                      l@t-t)ject     4@18t -  Iltilmonary  Di.sease.  '-f'lie  origi.nal  request  for                                       $26,400
                                               Component  I  was  for  $185,800  for  the  1-irst  year.
                      'I'liis II, @).@  [low been  reduced  to  $26,400.                 $22,000  of  this  total  is
                      I-or  P(,rsonyiel     .
                                             Disease  Component  will  be  conducted  as  a  small  pilot
                      portion  of  the  total  proposal.    It  @,7ill,  consist  of  a  one-month-long
                      program      for      physicians      and      nurses      desiring      to      learn      the      treatment      of
                      I)ati-c@nts      in      respiratory       failure.       "This       would       inciLide       instruction       i.n
                      (.establishing a  respiratory  care  unit  in  their  hospital,  experience
                      in  t@1)(@-  tisc,  of  all  equipment  utilized  in  the  care  of  these  patients  qs
                      %,tell.      ti-.Ieir      actLlll      management      duri.ng      the      acute      episode      and      through
                      the  recovery  period.    Instruction  i-n  the  technique-,  of blood  gas
                      analyzers  and  the  utilization  of  these determinations  in  patient
                      management  Would  be  provi-ded.                    Didactic  sessions  on 1)@isic  pulmonary
                      I)iiy.@iol.ogy  qrid  acid-base  balance  would  be  i.nclildecl."

                      LI
                           1.  To  enabl(-  pl)ysiciins  to  treat  and  manage  pati.enLs  in  respiratory
                                I-ailt,tre,  utilizing  latest  methods  and  equipment.
                           2.   'I'o  enable  nurses  to  cire  for  pati.ents  in  respiratory  f@,)ilure.,
                                including  proper  handling  of  tracheostomies,  prolonged  endot-i-,ichc@,@il
                                it-)Lttbntion,  utilizing  latest  techniques  and  equipment.
                           -3.  @'o  enable  physicians  and  nurses  to work cooperatively  in  the
                                care  of  patiei)ts  in  respiratory  failure  towards  maximizing  patient
                                benefits  from  latest  tecl-iniqt.ies  ind  equipment.
                      :'.@e-con(I  Year:    $22,500                               Third  Year:    $22,500
                      llrojec,t                 Closed  (Circuit  'I'elevi-sion  Prop-r@ini.                  The  original].                 $34,650
                                                request  for  Component  K was  for  $61,675  for  the
                      t  i.rs[  vc-!zii  .  'I'Iiis  has  now  been  reduced  to  $34,650.                      A I I  of  he i.s
                      ,intoiiii t @@ii I 1,  be  uril i-zod  to  -support  personnel.
                      According  to  the  Region,  Tile  Milwitikec@  Medical  'I'elevi,;i.ori  Net@,,.-ork  i,-@  I
                      fine  exiiiil)lc  of  interinstitutional  cooperation  with  tile  goal  of  enhancing





                                                      4 -           RI@l 00037 7/70.1.
          kqf,@(,ONSTN Regional Medical Program
                                                                             Requested
                                                                             First Year
          and .coordinating continuing education in the medical care and
          health fields.  It provides a focus around which the various
          institutions and professions can meet to consider their respective
          and joint goals in continuing education. Because  of  its  ability  to
          reach substantial segments of the professional  audience  any  given
          time, it is a means for communication with the  health  and  medical
                                            paralleled by any  other  means.  It
          personnel of the area which is un
          can provide the basis for evaluation of the effectiveness of various
          teaching techniques with large segments of the medical health pro-
          fessional groups in different settings, in different places, but with
          Common Source material. The development  of  local  programming  and
          filining of local material should provide the opportunity  for  inter-
          disciplinary and interprofessional groups to cooperate and formulate
          concerted.approaches to continuing education on an interdisciplinary
          basis.
          Television ProRram     roiect K - Obiectives.
              1. Coordinated production of T.V. programming for cooperating
                 health and medical care institutions.
              2. Provision of uniform educational content to health and medical
                 care personnel in  cooperating  institutions.
              3. Provide intensive T.V. media  programming  to fill gaps in
                 knowledge and abilities of personnel in cooperating institutions.
          Second Yeir-.  $34,650                 Third Year:  $34,650
          Evaltiat-loi-) -I.s planned at four levels. These  are:
              1. "])e extent to which the program has been established as approved
                 and funded, i.c,., staff recruited, readiness of facilities and
                 cclt.iiT),,nent, etc.
              2. otiantity of output as compared to  proposal.
              3. Qi-)a,'.itv or effectiveness of teaching.
                                 f new, enlarged or  revised  interinstitutional
                 programs developed by stimulus of this program.








                                                                                5/18/70





                                                                                                         A        Privil(,3(!cl



                                                                                   AlqD
                                                                                                          .z or
                                                                    1970 REV@l@i@7 CC)il"2@@@i'.@',Iklili'."@.,



                                                                    RY, 00037   7/70.1


                                          FOP, CI);'@SIDF@P-t@TI:O-.@,T L@Y JULY  1970                        CO'@LTI@CIL



                      General:   The Review Committee
                                        application            70.1 wi-ii,cli  reqte,-,,ts  $383,31@5  (d.c.0.)  b@,!  partially
                      fLtii(@le,d  a'(--              (d.c.o.)  to  support                              18A  for  a
                      prograrli pc@riocl.         Cc@ic,,@"flittee  furtlic4r  racc@,-;,-fte-rided  tlk@'t  ac,@,tion, on  C(i  puilel-@.t6l
                      ISB,   181   and   lsl'\,    bc--    1-@ort-al)provcl,    110    rliTS                reco,,fL,,i-iei.-ided.

                                        This                       T,?ns       ori-i),iall,y                  dui-i.,,)-_ July  3,969  I,,3
                                        a                       mciiipoi,@er                                     x.@ith eleven  sttb-
                      c 0 Fiji   Ti t s .     The                 progi:,ii@i would  establish  @i  multidiscii)ll.,i-i,-ry and
                      interii.i.,,,(:itutiorial.  approach  to  thc@                            of li,-,@,-ilth  -cicTice
                      ti@irou,  ti.   the                     of a                       of llealt,.Ii                      and
                      Eduic,@tl@ori    at    tile                  Sc@lool  of                                     cpl)ll"lte  trtiil-i@iz;g
                      coi                                  in     OctoLer      1969      the
                      cat'i,on be                      fi-or@l   thawed.   rcvi(.@w   proor-       Thir,  request
                      cause     of      c'Pticipat.(-,d  fiscfil                    rit.-s  ,it                        Du-i,ing
                      1970,    ttt(@     Regi(,,n                  tl-iit  tii(-,                      bL@                 to  Lli(,@
                      syrt(@iii   in    a                 form qnci  N.,iti-L rcr3uced                         Therc-,@forc,,  ttit,  Revic!@7
                                        corn  iclei--ed  o@,ily coT-,.-tponenti,             11,  1,          K.

                      Project  Cor@ipoi-ic,,,it                         t     @t .  0 f   (i
                                                                 (i u.  1Lj@ c,, I


                                                                                                          t   for  tlii,r,
                                        for tT.k(,@  f,,'.;cf3t yc!,!T@,r alleges  f,,I,30,4-00. This                    redt,@ced  to
                      .$50,765.         It I 7,-;  "41  (;'@ir UL o          a t       I', c 0   0 -@', e r I tI)ro@i)o@.. e@@ ",2t t
                      a  1)                of
                                        Y,,                                                            for                                    card




                                                                         by


                                                                                                             the                               ii


                                            b                          y                                                      t@o  ciL@.,,L.,bl.0  th,-
                                        to pro-@)c ic-.,  i            er,l)'i@,@c@@c).




                                                                      ,,.5 0 7,,',,.'                                              e;46,965







                       il.TISCCIII'- Sit.'f                                              2                             I'@@l 00037       7/70.1


                     Prc@ject  Col)  oat
                                                                                                                                      a n rl  1
                                                                                               p                  Pro

                     Critiqu,e:          ',Clio                               Njas                     in  re(,.criimetiding noia-approval
                                         of all  three  of these  cort-ipoiients.   Altliougli  the  total
                     originally          roqur--rted  tic-ive  b,lllc,@ri                            j@edu@ec-@d  in  the  tylodificte,  qp-
                     p I i c @-., t i o-@l. ,the                                  that:  these  Prci                     rc!qucsts  for  fui-ids
                     to          support persoiiiiel  into  are  ev.-@efcntl,y @ilrcady ernlil.oyed  by  the  institution.
                     In  addition,  the  eTil:i.rc-  ecluctitio@,iil  design  of  the xrarioi.%,@  components,  ,-IS
                     written,  v,@ex,e  conci(le7.-c@l                 k.

                     Recou@atirz,,ndc@tioii:   IZoia-approvel.  -  no RMPS  fliitdiii-  r(@coiirtiendcd.



                     Doctcsr  Philip Whit6  was  not  present  during                                                   on  this  applicati.o-,.i.


                                                                                               AI,7).)               OF
                                                                    1970



                                                                                                                 2ncl  Ye.,ir         3rd  Y(..iar

                       18           A               1,  fol-


                  Cor,ipotl,Clli:   1)@r)  rtf-@l I,-),t  C)I'                               $50,765             $46,965.             $46,965
                     ISA

                     IBB                      0                                      Ilozi@@approval             no RI'PS      funds  rc-cciriL,@,.c..,Yided

                     181           P117.rT"


                     18K              Clor,"%("


                                                                   TO'.PA L
                                                                                            $50,765              $46,965             $46  965




                  yc"?,  r                        To@,,zl

                  01)                                        $50,765
                  02)                                      6, 9  ()5

                  03)                                        40,9r)5
                                                                 695



                                                                                                                                          7/10/70



                               @ r-                                                                                                                                                                                                                                                                                          m
































                          0                                                                                                                                       0                                                                                                                                      0









                                    REGIONAL MEDICAL PROGRAMS SERVICE
                        SUMMARY OF A SUPPLEMENTAL OPERATIONAL GRANT APPLICATION
                                  (A Privileged Communication)

              WISCONSIN REGIONAL MEDICAL PROGRAM INC.            RM 00037 7/70.2
              110 East Wisconsin Avenue                          June 1970 Review Committee
              Milwaukee, Wisconsin 53202

              Program Coordinator:  John S. Hirschboeck, M.D.
              Requested              Ist  Yr.       2nd  Yr.       3rd  Yr.        TOTAL

              Direct Costs           $620,248        430,126        437,580        1,487,954
              Indirect Costs          104,893         41,792         42,095          188,780



                     TOTALS          $725,141       $471,918       $479,675       $1,676,734

              History:  The Wisconsin Regional Medical Program    Inc.  has been operating
                        under grant support from the Division of Regional Medical Programs
              since September 1, 1966. The first  year  of  a  two-year  planning  period
              began on that date with an award of $319,458 (d.c.).  During its second
              planning year the Region became operational, following a preoperational
              site visit in July  1967.  Therefore,  the  second  year  (9/l/67-8/31/68)
              award of $548,1866 (d.c.) provided continued  support  for  Core  planning
              and administration, plus support for  three  feasibility  studies  (two  in
              dial access tape libraries, and one for single concept films).  In
              addition, funds were provided to support three operational projects.
              These were in uterine cancer therapy, pulmonary thromboembolism and
              cancer chemotherapy for adults.

              The award for the period 9/l/68-8/31/69, was for $1,162,581 (d.c.).
              This provided continued support for Core activities, including the three
              feasibility studies mentioned above, plus nine operational projects.
              The Region is currently in its fourth year (third operational year,
              9/l/69-8/31/70). The total award  of  $1,689,510  (d.c.)  is  composed  of
              $1,548,430 basic and $141,080  carryover  funds.  (See  History  Supplement
              on last page for a breakout  of  this  total.)
              Present Application:  This application requests support for six
                                      (five new and one  renewal)  operational  programs.
              The renewal proposal requests one additional year's support for a
              project designed to prepare inactive nurses  for  return  to  the  practice
              of nursing.  The remaining five proposals are in the fields:  heart (3),
              cancer (1), and a proposal related to  high-risk  fetus  and  newborn  infant.
              Direct costs only are shown in the following program descriptions.






          WISCONSIN Regional Medical Program        - 2 -           RM 00037 7/70.2

                                                                             Requested
                                                                             First Year
          Project #13A (R) - Inactive Nurse Education -  University  of       $60,800
                             Wisconsin Extension. This  is  a  one-year
          renewal request for a project that, was approved for a two-year
          period, during the November 1968 Council, for $60,000.    The
          project initially was to start -March 1, 1969.  However,  because
          of funding restrictions during 1969, the project was  not  funded
          and did not become functional until September 1969.   The  Region
          states that an additional year's support is necessary to fully
          meet the objectives as originally stated.

          The overall objective of this renewal request is, to facilitate  the
          immediate and eventual return of the inactive nu rse to the  practice
          of nursing.

          The project plans to offer:   1) non-credit refresher courses for  inactive
          nurses in selected areas of the State; 2) a series  of  telephone/radio
          conferences on a Statewide basis; and 3) individual study  guides  on
          selected nursing topics.  The refresher courses will be patient-oriented
          and the enrollees will be assigned to care for patients  with  commonly-
          seen conditions that will be discussed in formal classes.   The  courses
          will provide the nurse with the opportunity to update  her  nursing
          knowledge and practice as well as to learn about resources  for  keeping
          this knowledge current.  The nurse will also learn  about  changing
          nursing skills and knowledge, organization, patterns of  care,  and
          current trends and concepts in nursing service and education.   It is
          planned to include in this course the projected plans for the  care  of
          the patient after he goes home, and information about  available  community
          resources.

          Three of these courses (four weeks each) were offered in the  areas  of
          Rhinelander, Neillsville, and Marinette during the fall of 1969,  and  a
          total of 17 nurses attended.  Seven of these nurses have returned to
          practice and an additional six plan to go back to work in the near future.
          Another course started in Sturgeon Bay in March and plans  are  under
          way to offer a course in Monroe, and another in Portage or West Bend
          later during the year.

          The television/radio programs are offered on an hourly  basis,  twice
          a month, and have 575 inactive nurses currently enrolled.   The sessions
          are designed to assist the inactive nurse in locating and using resource
          materials available to her.  The sessions also include  discussions  on
          recent developments in nursing, changes in medication, clinical aspects
          and community health.  The programs are taped and made available  for  loan
          to participants who are unable to attend the study sessions, and for those
          who are interested in forming study groups.

          The individual study gui-des will be implemented during the next  budget
          year, and 80% of the nurses who are enrolled in the  telephone  conferences






             WISCONSIN Regional Medical Program                        RM 00037 7/70.2

                                                                                 Requested
                                                                                 First Year
             indicated an interest in the service.  Some of the suggested
             topics to be developed include: 1) emergency care as  it  relates
             to shock, hemorrhage and childbirth; 2) nursing management of
             the patient with myocardial infarction (already developed);
             3) the burned patient; 4) the unconscious patient; 5)  congestive
             heart failure; 6) acute care; 7) disaster nursing; 8) psychiatric
             nursing, etc.
             At the conclusion of this project, the individual study units and
             the telephone conferences will be phased into the ongoing programs
             of the Department of Nursing, at the University of Wisconsin Extension.
             An overall evaluation of the enrollees will be conducted  at  the
             conclusion of the project, to determine the extent of the  return  to
             practice of the enrollees.  The evaluation forms include: 1) a refresher
             course questionnaire (mailed six months after course terminates);
             2) listener's response sheet and interim survey sheets for telephone
             conferences; and 3) evaluation form for individual study unit.
             Approximately $44,000 of the total request of $60,800 is for personnel
             and consultant services.
             Project l@19 - An Educational Program to Improve the Care of  the      $136,040
                           High-risk Fetus and Newborn Infant - University  of
             Wisconsin.  This project proposes to organize and coordinate a
             limited number of specialized facilities which would be  used  as
             referral centers for the care of special problems related to  the
             high-risk fetus and newborn infant.
                                             I
             Plans are to develop at least f4-ve regional centers in La Crosse,
             Madison, Marshfield, Milwaukee And, tentatively, in Green Bay.  These
             centers would provide intensive care for the high-risk  newborns  and
             specialized care for high-risk pregnancies during the antepartum and
             intrapartum periods. In order to provide  the  necessary  trained
             personnel to staff the centers, several educational programs have
             been developed. One program would be aimed at  preparing  nurses  who
             are currently employed in intensive care units for the newborn
             which do not have instructional personnel to meet the need of
             orientation and ongoing inservice training.  This program would be
             offered concurrently in Madison and Milwaukee over a two-week period.
             A second program would be aimed at preparing nurses who would be caring
             for infants following their hospitalization in an intensive care unit.
             The infants may be transfer patients still requiring hospitalization,
             or may be ready for discharge. The nurse would be  prepared  to  give
             continuity of care and subsequent followup into the community.  A
             third program would involve consultation services made  available  to
             hospitals and communities for the purpose of training nursing personnel
             to recognize the high-risk mother and infant.





          WISCONSIN Regional Medical Program         - 4 -          RM 00037 7/70.2

                                                                              Requested
                                                                              First Year
          The Madison Regional Center Program is designed to serve hospitals
          in the State of Wisconsin (except'the Milwaukee Region) and  could
          also be available to hospitals in Duluth, Minneapolis, St. Paul
          and Southeastern Minnesota.  At present, there is an active intensive
          care center. An enlarged intensive care nursery  is  under  construction
          and will have space to accommodate up to 28 high-risk infants.  It
          is planned to operate 4-5 classes yearly, with a limit of four nurses
          per class in the first year - later expanding to five or  six  nurses
          per class. The instruction will take place primarily  in  the  intensive
          care unit at St. Mary's Hospital in Madison.  The  nursery  accommodates
          2,000 newborns per year.
          The Milwaukee Regional Center has a 25 to 30-bed intensive  care  unit
          at Milwaukee County Hospital and serves Milwaukee County  and  South-
          eastern Wisconsin.  The program will be conducted in the Milwaukee
          County General Hospital obstetric and nursery areas and  will  operate
          four to five classes per year, with four nurses per  class  initially,
          later expanding to five-six. The hospital has a total  of  1,500  births
          yearly and more than 30% of these fall into  high-risk  groups.  From
          the previous capacity of 15, the intensive care facilities  are  being
          expanded to accommodate 20 babies.
          The La Crosse Regional Center serves the Western area of Wisconsin
          and.adjacent areas of Southeastern Minnesota.  The target group
          would be the nurses in the La Crosse Regional Newborn Center at
          St. Francis Hospital, the nurses from referring  hospitals  within
          the Region, and physicians involved in neonatal care within the Region.
          The educational program would be conducted on a weekly  or  bi-weekly
          basis, utilizing resource people from the Madison  Center  program
          to participate with the La Crosse Regional Center nurses in the
          development and presentation of the program.  The program for the
          nurses from the surrounding area would be held at the  Regional  Center,
          on a one-day seminar basis - two or three times yearly, and would
          involve lectures, demonstrations, and  in-the-unit  participation.
          Bi-monthly or monthly perinatal mortality conferences  and  perinatal
          care seminars will be conducted for the physicians.
          The Marshfield Regional Center          is designed to serve the North
          Central Region of Wisconsin.  The target group will be the nurses
          within the regional newborn center, the nurses from referring hospitals
          within the Region, and physicians involved in neonatal care  within  the
          Region.  The organization of the'course follows the same design as
          the program described for the La Crosse Regional  Center  Project.
          The development of a center in            is currently under  way.
          This center will provide service to the Northeastern Region of
          Wisconsin. For the next two years the  developmental  and  educational






             IJISCONSIN Regional Medical Program       - 5 -           RM 00037 7/70.2

                                                                                Requested
                                                                                First Year
             aspects of the program will be carried on from the  Madison  Center.
             The educational program will be evaluated by:  1) written pre
             and postcourse tests based upon behavioral objectives-,     comments
             from the participants; and 3) followup visits to  the  participants
             by the teaching staff.

             $114,240 of the total request of $136,040, for the first year,
             is for personnel.

             Second Year:  $132,840             Third Year:  $132,840

             Project #20 - An Action Program for Detection and Management         $116,125
                           of Gynecologic Malignancy - University  of  Wisconsin
             Medical Center. This project is an outgrowth of  the  Study  Program
             for Uterine Cancer Therapy and Evaluation which has been funded
             through 8/31/70.  This is a request for a one-year program to
             develop a network of regional centers designed to make available
             the techniques of colposcopy and directed biopsy to  the  physicians
             of the State and their patients.  The present centers involved are:
             The University of Wisconsin Medical Center, Madison,  Marquette  Medical
             School-County Hospital Center, Milwaukee, St. Mary's Hospital,Milwaukee,
             and the Marshfield Clinic, Marshfield. New centers  will  most  likely
             be developed at La Crosse and Green Bay, Wisconsin  and  Duluth-Superior
             (Wisconsin and Minnesota).

             It is hoped that by substituting these techniques for  the  evaluation
             And management of patients with abnormal cytology, the use  of  the
             surgical cone will be reduced, thereby reducing hospital  costs  and
             surgical hazards.

             An informational program will be implemented to  inform  physicians
             of the advantages and availability of colposcopy and directed biopsy.-
             The information will be disseminated through: 1) RMP  newsletters  and
             releases; 2) State Laboratory of Hygiene newsletter; 3) State  Board  of
             Health publications; 4) Wisconsin State Medical Journal briefs;
             5) dial access tapes; 6) circuit seminars among the County Society,
             Councilor District meetings, etc.; 7) direct individual  contact  with
             physicians; and 8) "detailing" by county agents on the latest advance
             in medical developments.

             When it is judged that a reasonable physician understanding  has  been
             achieved, the State Laboratory will begin to include with each physician's
             report of abnormal cytology information on where and when  this  service
             can be obtained.  The names of both physicians and patients will be
             distributed (at regular intervals) to the centers that are located in
             close proximity to both the patient and the physician.  An attempt will
             be made to explain this service to the physician and to  elicit  his
             understanding and participation. When this is  achieved,  the  physician





         @4ISCONSIN Regional Medical Program          - 6 -           RM 00037 7/70.2

                                                                                Requested
                                                                                First Year
         will send or bring his patient to a prearranged colposcopy clinic
         at one of the centers where a repeat cytology and directed biopsy
         will be obtained as colposcopy is performed.  A report will be
         sent to the patient's physician within 48-72 hours, with suggestions
         regarding further  diagnosis  or  therapy  where  appropriate.  Followup
         on all contacts will be maintained  by  the  cooperating  centers,  the
         State Laboratory of Hygiene and other participating agencies.
         Every effort will be made to  maintain  uniformity  between  centers  in
         the collection of data concerning tissue interpretation and
         demographic information.

         Patient fees will be maintained at a  re. inimum and  will  be  initially
         limited to institutional charges.  Professional charges for the
         diagnostic colposcopy and biopsy will not  be  made  to  referred  patients,
         unless these patients are referred for definitive treatment.  Indigent
         patients will be cared for  at  no  cost.
         The applicant states that an interregional relationship (Section 9-10)
         is being developed with neighboring Regions  such  as  the  University  of
         Minnesota and,the University of Iowa which will allow:  1) their use
         of dosimetry programs currently available  in  this  center;  2)  their
         participation in clinical data  collection  and  tabulation  in  gynecologic
         malignancy; and 3) the joint utilization of ideas, expertise and
         facilities of any one of the  institutions  by  all  participating  centers.
         The budgets in the application for Iowa and Minnesota are samples rather
         than requests for funds.
         As a means of evaluating the success of  the  program,  the  number  of
         patients being coned each year in the projected  Regions  or  in  the  State
         as a whole, will be determined for a  specific  period  of  time.  If  the
         program is successful, it is expected there will  be  a  decrease  in  the
         number of surgical cones and an increase  in  the  number  of  colposcopic
         studies with biopsy. A second  approach  to  evaluation  will  be  possible,
         utilizing physician understanding of the place of colposcopy and directed
         biopsy as an indication of success.
         The preparation of a uniform reporting and evaluation system for
         gynecologic malignancy in the multiple Regions served should also be
         an indication of success.

         Staff was advised by the Program  Coordinator  that  the  Wisconsin  RAG
         approved this proposal for one year to afford them an opportunity
         for a  complete  evaluation  o  progress.

         Second Year:  None                      Third Year:  None






            WISCONSIN Regional Medical Program          - 7 -         RM 00037 7/70.2

                                                                                Requested
                                                                                First Year
            Project #21 - A Computerized Electrocardiogram Project for            $124,581
                          Wisconsin - Marshfield Clinic Foundation.  This
            is a three-year request for a proposal which would provide a
            centralized electrocardiographic interpretation service for the
            ',Iisconsin Region. The system would offer four distinct  advantages:
            1) direct service to the patient and physician;  2)  decreased  cost;
            3) increased speed of interpretation and application of  the  results
            to the patient; and 4) better and more efficient utilization  of  the
            cardiologist's time by assisting in the interpretation of more tracings
            in less time.


            The initial target population will be those patients  served  by  the
            following hospitals: 1) Park Falls  Hospital,  Sacred  Heart  Hospital,
            Ashland Community Hospital, Oconto Falls  Hospital,  Adams-Friendship
            Community Hospital, Medford Hospital, St. Joseph's Hospital, Marshfield
            Clinic, Neisville Memorial, and Black  River  Falls  Hospital.  These
            hospitals have a total bed capacity of 1,004 and  run  25,111  electro-
            cardiograms per year. Most of the hospitals are rural  and  only  one
            (St. Joseph's) has a full-time cardiologist.  The eventual target
            population would include over 9,000 hospital patients in  the  State.

            The project will be administered by the  Marshfield  Clinic  Foundation
            for Medical Research and Education.  The cardiology, electrocardiographic,
            and the computer services of the Marshfield Clinic will be utilized to
            provide the personnel, equipment, and technical services.  The educational
            programs will be provided by personnel from the Foundation, the Clinic
            and the 3M Company.

            The first three months of the project will be spent  setting  up  the
            central operation (to be located within the Marshfield Clinic), training
            personnel and checking computer programs.  A training program for technicians
            will be established and will involve an intensive program in EKG analysis,
            interpretation, and the use of the equipment for  taking  EKG'S.  The
            Marshfield Center technicians will be trained on site and the technicians
            from the cooperating hospitals will spend an initial week at the Clinic.

            Formal and informal seminars will be held in each  of  the  cooperating
            institutions for physicians in an effort to familiarize them with the
            computerized EKG program and how it can be used as a  service  to  both
            the physician and the patient.

            The second phase of the program will begin at the end of three months.
            At this time EKG's from the Clinic will be run to verify the programs
            and to establish the procedures to be used.  In addition, during this
            phase of the project, the trainees from  the  cooperating  hospitals,
            along with local hospital personnel, will receive further instructions.





          WISCONSIN Regional Medical Program              8 -            RM 00037 7/70.2
                                                                                   Requested
                                                                                   First Year

          The third phase of the project will begin approximately six
          months after initiation of the service to the regional hospitals.
          During the second year of the project, 10 to 15 additional hospitals
          will be incorporated into the network and 10 to 15 more in the
          third year.
          This program will be evaluated in five stages.  The initial stage
          will be  verification  of  the  computer  program  and  interpretation  of
          the electrocardiogram by the center's staff cardiologists.  This
          will be done for all electrocardiograms for the first six months,
          on a random basis.
          The second portion of the evaluation will deal with the user increase
          of the  program.
          The third evaluation stage will attempt to determine whether or not
          the  computerized  electrocardiogram  actually  supplied   the   physician
          with the data which is useful in his diagnostic determinations.  This
          will be tested in all cooperating hospitals.
          The fourth phase of the evaluation plan deals with computation
          of the cost of the electrocardiograms.
          Finally, continuing  evaluation  of  the  geographic  area  to  be  served
          will be made, to insure  that  the  service  will  be  made  available  to
          all areas which have a need.
          At the end of three years the project will be taken over by the
          Marshfield Clinic as a service function.
          $45,408 of the first year's total request of $124,581 is for personnel;
          $70,773 is for equipment; and $8,400 is requested for supplies and travel.
          c-econd Year:  $125,667              Third Year:  $128,533
          Project  #22  -Community-Oriented Continuing Education in                 $54,341
                         Rehabil tation Medicine for Physicians and
          Allied   Health Personnel - Division of Health, Wisconsin
          Department   of Health and Social Services.  This is a three-year
          request  for  aproject to provide physicians and allied health
          professionals  with an opportunity to develop skills, increase
          their  knowledge,  and  to  improve  the  coordination  of  rehabilitation
          activities.
          The target area  is  a  three-county  nonurban  area  located  in  central
          Wisconsin.  All three counties have a significantly higher percentage







             WISCONSIN Regional Medical Program        - 9 -             RM 00037 7/70.2

                                                                                   Requested
                                                                                   First Year
             of people in the 65 and over age group than the State as a whole.

             The project's objectives are:

                1) To improve the ability of physicians in the target community
                   to respond to patients' r@.eeds for treatment and  rehabilitation
             through participation in interdisciplinary educational programs.
             As a result of these educational programs, it is  anticipated  that  the
             physicians will be able to identify  potential  or  actual  disability,
             and determine the degree to which the condition diminishes the patient's
             ability to cope with his environment.  In addition, the physician
             will be able to select and prescribe the appropriate therapy to
             minimize or prevent disability; and will also be able  to  contact  and
             identify the appropriate allied health personnel to provide specialized
             therapy services when needed;

                2) To improve the ability of allied health  professionals  to  assist
                   in the process of providing complete and coordinated care to
             patients in need of rehabilitation,  by  participating  in  educational
             programs. As a result of this objective,  the  allied  health  personnel
             will be able to determine the extent of the  patient's  disability  and
             relate it to current techniques of their specialty.  They  will  be  able
             to recognize the needs of the patient for services which go beyond
             their own area of competence and training, and  make  proper  referrals.
             In addition, the allied health personnel will  be  able  to  adequately
             perform their functions and provide their services  in  locations  that
             lack the facilities ordinarily available in  a  hospital  setting;  and
             will be able to adequately perform consultative, teaching, and
             supervisory services.

                3) To provide health professionals, persons in need of rehabilitation
                   services, and their families with a source of  information  on  the
             full range of rehabilitation services available in, or  to,  the  target
             communities.


             The educational activities to be conducted  include  individual  patient
             consultations, rehabilitation evaluation clinics,  and  formal  teaching
             sessions.  Consultation (provided by therapy consultants from the State
             Division of Health) to individual agency  administrators,  allied  health
             professionals, and key agency personnel will be made available upon request.

             A referral and information service will  be  developed.  Information  on
             local, area and State resources will be compiled by the local coordinator
             with the assistance of the @IRMP staff.

             The rehabilitation evaluation and teaching clinics will be  held  for  a
             full day once a month in each community, for a period  of  ten  months;
             and will be carried out by the project physicians and the therapy
             consultants and, occasionally, other medical  or  technical  specialists.





          WISCONSIN Regional Medical Program         - 10 -       RM 00037 7/70.2
                                                                           Requested
                                                                           First Year
          Evaluation methods of Objectives I and II include:
            a) Pre-tests and post-tests to determine the health
               professional's knowledge of such factors as the
          identification of disability, appropriate therapy, current
          techniques, etc.
            b) Pre and post-use of a structured study to determine
               their understanding and concern with the  patient's  needs
          in rehabilitation.
            c) Observation of course participants in a clinical setting.
            d) Examination of hospitals' and physicians' records on
               disabled patients who receive care during the project period.
            e) Examination of nursing and other allied  health  personnel
               care plans and records, for information on sources of
          referrals, their types of functions, patients' treatments,  and
          consultations.
          Method-s of evaluating Objective III (which relates to the establish-
          ment of a referral and information source) include a survey of patients
          and/or their physicians with rehabilitative needs, to determine the
          number of persons aware of the service and number who have utilized
          the service.  Those using the service could also be surveyed to
          determine.whether or not they actually received the services they needed.
          Approximately 16% of the first year's total request of $54,341 is
          in the personnel category.
          Second Year:  $57,428              Third Year:  $62,016
          Project #23 - An Educational Proaram for Cardiac and  Intensive    $128,361
                       Care Nursing - University of Wisconsin, Milwaukee.
          This is a request for three-year support for a proposal to
          establish a comprehensive intensive and coronary education program
          for registered nurses in the Wisconsin Region, in an effort  to
          improve the availability, effectiveness and efficiency of registered
          nurse manpower to hospitals with ICU-CCU.  Plans are to provide
          training for 72 registered nurses each year of the three years.
          During the third year it is also planned to conduct workshops with
          School of Nursing faculties to identity that ICU-CCU content which
          should be included in basic and graduate nursing curricula.
          The core training program will be developed at the University of
          @qisconsin-Milwaukee School of Nursing in collaboration with
          Marquette University Craduate Department of Nursing, and Marquette
          School of Medicine.






            WISCONSIN Regional Medical Program          11 -          RM 00037 7/70.2

                                                                               Requested
                                                                               First Year
            The teaching program is planned for five days per week for a
            six-week period.  Four hours of each day will be devoted to
            theoretical instruction and four hours to clinical experience.
            Of this, two hours are allotted to planned formal classes, one
            hour is allotted for self-study, and one hour for seminar and
            group discussion work and films. The seminar and  group  discussions
            will include various resource people such as dieticians, social workers,
            clergymen, Public Health nurses, and a former patient.
            The trainees will be selected according to the following criteria:
               1) The trainee will have at least one year of postgraduate nursing experience;
                  will have been employed within the past year; and will be a
            licensed registered nurse.
               2) Preference will be given to trainees with experience in ICU/CCU
                  and emergency room.
               3) The trainee will have an employment contract to work in nursing
                  during the ensuing year.
               4) The sponsoring hospital will be asked for a written commitment
                  to support the trainee in what he has learned.
               5) !,Then the trainee is from a hospital, the physician responsible
                  for the CCU-ICU will agree to participate in two seminars
            conducted during the course of the training program.
               6) The hospital will agree to participate in a followup evaluation
                  and consultation visit involving the hospital administrator,
            director of nursing, and responsible physician.
            The applicant states that the objectives are described in terms of
            behaviors to be achieved at the end of the course.  Evaluation  then
            becomes a measurement of the attainment of these behaviors.
            Approximately $47,000 of the first year's total request of  $128,361
            is for personnel and $43,344 is for stipend allowance for 72 trainees.
            Second Year:  $114,191               Third Year:  $114,191








         WISCONSIN REGIONAL MEDICAL PROGRAM            - 12 -               RM 00037 7/70.2


                                            HISTORY SUPPLEMENT


         LISTING OF CURRENT STATUS OF CORE SOPRRATTONAL PROJF.CTS TN WRMP

         PROJECT  TITLE                                                 AMOUNT SUPPORTED   (D.C.)
         NUMBER                                                          THROUGH 8/31/70
                                                                       BASIC       CARRYOVER

           I       Core                                                $438,974

           2       Study Program for Uterine Cancer Therapy
                   and Evaluation                                      105,032

           3       A Pilot Demonstration Program for
                   Pulmonary Thromboembolism                            55,404

           4       Cancer Chemotherapy for Adults                       38,492

           5       Postgraduate Education for Health
                   Professions                                          58,520       --

           6       Interrelated Programs in Radiology and
                   Nuclear Medicine                                    112,059       11,141

           7       The Prevention, Diagnosis and Treatment of
                   Cardiovascular Disease
                     Part B - Coronary Angiography                        5,800
                     Part C - Pediatric Cardiology                      57,374

           8       Cancer Chemotherapy Program for    the
                   Metropolitan Milwaukee Area                          66,725

           9       Community-oriented Continuing Education in           Approved   no funds
                   Stroke Rehabilitation for Physicians and             recommended
                   Allied Health Personnel

         10        Coonerative Project in the Diagnosis and            Approved -  no  funds
                   Treatment of Secondary Hypertension                 recommended

         11        Tissue Typing Program                                51,350

         12        Uterine Cancer Screening Project                     48,700

         13        An Operational Program for Nurse    Training
                   (Two parts)
                     A - Inactive Nurse                                 60,000       --
                     B - Nurse Shock                                     --          12,400







         TAIISCONSIN REGIONAL MEDICAL PROGRAM       - 13 -             RM  00037  7/70.2

         LISTING OF CURRENT STATUS OF CORE & OPERATIONAL PROJECTS IN WRNP (continued)

         PROJECT  TITLE                                              AMOUNT SUPPORTED (D.C.)
         NUMBER                                                      THROUGH 8/31/70


                                                                  BASIC       CARRYOVER


         14        Cardiopulmonary Resuscitation Project             Nonapproval

         15        A Comprehensive Program in Renal Disease     $ 450,000
                   (Note:  This project was approved for a
                   three-year period.  The Division is
                   currently negotiating a $450,000 annual
                   level of support)

         16        Medical Library Service                                        16,950

         17        Nurse Utilization Demonstration Unit                          100,589


                                           SUBTOTAL             $1,548,430      $141,080


                 GRAND TOTAL (BASIC AND CARRYOVER)                   $1,689,510



























                                                                                    DRMP
                                                                                   4/30/70






                                                                                                                                           17 i V     e   C-.,d    c, II II


                                                                                                                         -i.r         0      oi@
                                                                    Stil'T@ilill,@@7  CJ7
                                                                               1.9'/()                   CO-" I I'J'T i@ 1.


                                                                    WISCONSII'4'  l@EGIC)@\IAII
                                                                                               0OCi@117             7/70.2


                                                       FOk                                    BY      J',@j!:Z       191'0                     COT.TNCIE.

                         C or c.,, r,-i 1.     '."he  Rev,--ew  Cori,,iiiittee                                                               supplemental-  operational
                                               ,-pplicatio-i-i        --        7/70.2        -        which        rc-tl,--,c-rts        $1,487,951+        for        a        tlll.-ee-year
                                          I)criofl,         be         partially          funded          tt          $551,60,',          d.c.o.    This  is  to  support
                         Pi-o@@cts  Y@-20  and  Y@22  i-ri  the                                  enC').  tmou-t-it  i,e-quected  and  Project  YF23  in  the
                         time             recluc-..@,,ted,  in  a  reduced  aa,lota,,it.                    Cor-iiiittee  further  recommended  )pl)i@t)val
                         of          Project          #13A  (R)        for        them.        time        requested        but        did        not        recommend         addit,,-c)i-ial
                         f uncl           P    c)  c (-@ t  il-19  wj,.-@                                for           deferral           periling           technical            revie,,y
                         by  tl,.@,                         and  Cl-iild  He,).Ith  Staff.                         Coniriittec,@  recommended  t@li@it  Project  #21.
                         not:       be        ap-p@rovc@e,  -  no                 funding                                         I'c      was       further       recorrr,-n,@,ii       e
                         that  Council.  conlje-.Ie  a  committee  to  exp!6r(-!  ,.re@2s  of  computer  assistance  9,iid
                         monitoring           'Dy           re-Laote           cor@trol           devices.

                         Project       Yi':I.3A       (R)       -        inact@i.vo@        NLirse        ECI(ic,@it:ioii.

                         (,'r 1.    vi., e @     Committee  noted  tliit  this  @,7a-.  a  one-year  rene;4al                                                                 -.oi-      a
                                                 project       that       T@7as       approved       for        a        tt.)o-yeir        T.)rogrz,,iii        13e!,---,.od        during
                         thc@                        1968  CoiL).ncil.                Ilo@@7ever,           t-eceu,,;e           of           fundiiAg           restrictions           during
                         l@969,   the  project  N,7js  not   funded  and  did  not  becoEfia  functional.  tint-Il.'L
                                               1,969.

                         Wli@Lle       the       '-'oDT@-nittee       agreed       that       the       need       for       tlii.s       type       of       program        is        cleai-I
                         results   fro,-P.  programs  of  this  type  -eiie)-al'Ly  are  'Poor.  Apparently,   this  -,Ls
                                                                                                     rD
                         true  with  this  program  since  only  seven  out  of  17  nurses  who  have
                         are  icttiall.y'back  on  duty.

                         Mt--rr@,bc.@rs  of  the  Committee  noted  the  review  and   favore,i)]-e  i-ecorf@riiel-i  q-tioi-i
                         of  tlte  Continuing  Education  and  Training  Branch  Staff  pertaining  t:o  tlii..@;
                         pro Po

                         In  recoii@t@Tc@ndin@  approvpl,   the  Co@nmittc-e  believed   that  the  c)-Lie-year  additiona
                         time  period  reouested  may  serve  to  assisti  the  project  in  meeting  its
                                                     Ilo@,7evc-.r-,   it                recommended         that.         no         additional         RI-,IPS         funds         I,C,
                             i
                         allec,,@@ted  to  this  activity.

                                                                                 in  triple,  with  i-i,)                                      IZM,':'S   funds  reco-!i,,inendc-,cl.

                         Pro'ic-,ct.  @,,@1.9  -  l@n  Educational                                       to                               Ci37(@  Of  the
                                                       Fe.t,,ir.  and  Ne@171)'orp,

                         C r,;', t@ i (4, (i c,. :The                                                                          %?!.tl)  the  revi4--@,7  of  the  AO,  Iloc
                                                 Carcliovasctilai.-          St:tl@ly           Pai-,c.@l.                              that   the  proposo-I  is  wcll
                         r@ I-         c: f)     the  -faced                                                             tIlCi                              C)i)  C-Cl@i@)E'-,@,      )--e
                                                            clear  end                                                     of                  tc,  E-tc--corllpl-isl?  the
                                                  1)@)   t
                                                                orl,,  iT-,-i.jor                               iic>t(.,d  I.f7,                                  of  life  this
                                                 in






           WISC.ONQIN Regional Medical Program                             RM  00037  7/70.9

           It was noted that the re was no clear evidence that nurses  are  available  to
           participate in this specialized training and function.

           The Committee debated whether to recommend approval of  this  proposal  for  two
           years, with specific conditions, until a Program  Coordinator  (who  was  serving
           69 an ad hoc committeeman) suggested that the proposal  be  reviewed  by  the
           Maternal and Child Health Staff-.  From prior knowledge, he believed that
           similar types of programs were being supported out of Maternal and Child Health
           funds. The Committee accepted his recommendation  that  no  action  be  taken
           pending a technical review by staff of Maternal  and  Child  Health  Services.
           This has been requested and should be available in  time  for  Council  meeting.

           Recommendation:  D&ferral pending review by staff of Maternal and Child
                            Health Sorvices4

           Prbj'ect #20 - An A6tion ProRram for Dot6ction and ManaRement of CynecolbRic


           Critique:  The Review Committee noted that this is a worthwhile cancer project
                      in spite of believing that there is  little  interest  in  colposcopy
           in the United States. The Committee was  interested  in  the  statement  that
           this will be a part of an interregional relationship (Section 910) which is
           being developed with Wisc6nsin's neighboring Regions -  Minnesota  and  Iotqa4
           When this re 16tionghip is developed, it will provide for:  1) use of
           @@d6simotry programs currently available in Wisconsin by the  participating  out-
           lof-S@tate Universities; 2) participation  in clinical data collection and
           tabulation in gynecologic malignancy; and 3) the  joint  utilization  of  ideas,
           expertise and facilities of any one of the  institutions  by  all  participating
           centers.

           The budgets shown in the application for Iowa and Minnesota are samples rather
           than requests for funds.

           In addition, the reviewers noted that the Wisconsin  RAG  had  approved  this
           proposal for one year only to afford an opportunity  for  a  complete  evaluation
           of progress,

           Recommendation:  Approval in time And amount    requested.

           Direct Costs Only:       Ist Year        2nd Year        3rd Year
                                    $116,125       Tiohe requested , None requested

           Project #21   A computerized El@ectrocard@aT @r@ect      for Wisconsin

           Critique-  The Committee concurred with the opinion of   the Ad Hoc Cardiovascular
                      Study Panel that although a limited need for  this  type  of  service
           by small hospitals in rural Wisconsin  is  described,  the total forecast of need
           by all small Wisconsin hospitals is not  adequately  documented.  It  was  agreed
           7
           that while the objectives are quite  clearly  stated,  the "state of  the  art"
                                                      I
           f computerized ECG interpr etation is not as advanced  as  indicated  in  this





           WISCONSIN Regional Medical Program             - 3 -           RM 00037 7/70.2

           The reviewers questioned whether it was  realistic-to  assume  that  a  physician
           can be trained to understand and use ECC interpretation in a four-hour session.

           Tb6 method of evaluation proposed is unrealistic  in  that  the  Medical  Systems
           Development Laboratory of  the  Public  Heal th Service is no  longer  available
           for consultant service.

           In recommending nonapproval, the Review  Committee  accepted  the  Panel's
           conclusion that the application is unapprovable on technical grounds.
           Committee urged R14P Council to take action to convene  an  expert  consultant
           committee to explore the entire area of  computer  assistance  and  monitoring
           by remote control devices.

           Recommendation:  Ndnapptoval - no RMPS funds recommended.  The Comnittee
                             recommended that the RMP Council take action  to  convene  a
           consultant committee to explore the entire area  of  computer  assistance  and
           monitoring by remote control devices.
           Pr6j4ect #22 - Community-oriented  Con'tinui  Education  in  Rehabilitatio
                                                      LI L E-C, I -                 a
                         Medicine for Physicians and Allied Health Personnel.

           r@lt@ue: The Review Committee relied  on  the  comments  made  regarding  this
                      proposal during the review conducted by the Continuing Education
           and Training Panel.

           The educational design of the program is considered adequate.

           In establishing a need for the projects the  applicant  has  done  the  necessary
           pr6plAnning which includes: 1) the use of statistics  on  the  extent  of  the
           problem; 2) the experience from other States; 3)  review  of  the  literature;
           4) a survey of existing resources; and 5) lack of manpower in the rehabilitation
           field.

           members of the Committee agreed with the Panel  that  the  objectives  are
           stated in measurable terms..

           The Committee observed that the pr6gram,will:

             1) Utilize many staff members from other agencies.
             2) Establish an Advisory Committee which will  involve  many  resources  and
                which will provide general guidanc&, interpretation, and liaison for
           their organizations. This will be  the  primary  group  with  the  responsibility
           for planning the continuation of the activities  at  the-end  of  the  three-year
           Or6joect period. The applicant states that  the  State  Health  Department  will.
           continue the activity if it proves successful.
             3) Develop cooperative arrangements throughout the Region.
           The Review Committee agreed with the Panel's recommeiAdAtion-of approval
           since this appears to be a technically sound and  ea  ably  directed  program.
                                                                 p
                             Approval In time and amount requested.
                                    ist Year        7ild Year       3rd Year
                                    $54,341         $57,428         $62,016






           WISCONSIN Regional lledical Program                    4              RM  00037   7/10.2

           Project Y@23 - An Educational PIO@ram--fo-i---C-a-i-diac and  Intensive Care

           Critique,    The Review Committee considered the review        of  the  Ad  Hoc  Cardio-
                        vascular  Study  Panel.  Committee  agreed  with  the   Panel   that   the
           objectives   are clearly stated and should be attainable,providing appropriate
           applicants   are available for training.

           A    question was raised as to the appropriateness of a six-week course for
           CCU    nurses as  compared  to  the  usual  four-@jeek  courses  but  it  was  recognized
           that six-week courses may be appropriate for intensive care training for nurses.

           Although  the  resources  appear  to  be  adequate,  a-question  was  raised   as   to
           physician  involvement  in  the  training  program.  This   point   is   not   covered
           in the application.

           The amounts requested for equipment, stipends, and publications were considered
           excessive.  The necessity to develop and produce one dozen thirty-.minute video-
           tAp6s ('In view of the request of R.OCOM) was questioned.

           The estimated $2,000 per capita cost is high when compared to a per capita cost of
           approximately $1;000 for similar courses funded by the Heart Disease and
           Stroke Control Program.  The Committee believed that the          Region should attempt
           to persuade the  University  of  141.sconsin  to  @,7aive  the  $115  tuition  expense
           requested.

           'the reviewers concurred with the Study Panel's conclusion that tb6 application
           is technically sound and capably presented but the budget is excessive.
           Therefore,  as  a  condition  of  approval,  the  Review   CoiTmiitt6eArequested   that
           Staff  suggest  budget  reductions  which  would  bring  the  cost  of   tbi   program
           in  line  with  the  cost  of  similar  programs.  Staff   suggested   the   following
           first-year bu(het:
                                                                                   Direct    Costs
                                                                                 From      To
             Personnel  (reduce.  Project   Director's   time   and
                          salary by 10'/.).                                   $   46,997    45,064
             Consultant Service                                                  6   000   6,000  (same)
                   Mont (deletes $6,000 for Multimedia
                          Instructional System).                                  14,170   8,170
             up    Ites                                                         2,300     2,100
                ,p
             Travel   (by reducing amount for trained       travel)              6,500     5,750
             Publications                                                        3,750     3,750 (same)
             2the'r (Development of videotapes)                                  5   300       0-
             Stipend Allowance                                                @@3    344  2 l@ '@4
                                                       TOTAL                    $129,361    92,678

           $84.;508 per year, for e@tcb of- two years, is the amount ,,uggested        for the
           second  and  third  year,  The  reductions  are   principally   in   trainee   stipends
           and travel.

           Recommendation.  Approval    Iin time with tiie amounts and conditions as
                               st@a-ted above.
                 t Costs 0-nly4      lst Year        2nd Year        3rd Year
                                     $92 678         @84.,508        $81@,508
   i       'n- 'Di, II,,- T@Tl, -I4--. .,, - --i- AI,@; ,@ elnl   --If-4 nr, nf thi o- -inn l 4 ri i-i c),,-i -












              ,/@IOCO' SII,7@. P,(-
                              _@,,ional  I,,Iedical  Prograiii                                 RM 00037 7/70.2

                                                                               -O'
                                               SL'14,,,IAIZY OF                   iqS


              Project
              Number       Title                                                 Year      2nd Year          3rd Year

              13A (R)      Inactive l@urse Education                     Approval       no additional funds
                                                                         recommended

              19           An    Educatiol;ll_l@o@,'LIM     to           Deferral for special review (MCII)
                                           Care of the 1-1 Rh-
                           risk Fetus and Nc@@,il-)oryi Infant

              20           An   Action    Prof,,--ram    for    Detection    $116,125      None              None
                           and ManaReti@@nt of CynecoloRic                                 requested         requested
                           mali@na2-c2

              21           A   Corny)t-lt'erized   Electroca.i.-di-o@,rarti   Nol-iapproval - no RMPS funding
                           Project                                              recommended

              22           Coi-ft-@iiiinity-ori.ented Co                 $    54,3141      57,4?8            62,016
                           Education ii-i Reliabilitati-oii
                           Medicine for Physici6ns and
                           Allied Health Personnel

              23           An Educ,).tio,-ial ProRram for                $     92,678      84.,508           84,508
                           Cardiac and Intensive Fire
                           Nursing

                                                        TOTALS           $263,144         141,936           146,524

              YEA,RS                                                              TOTAL       DIRECT COSTS

              01)                                                                           $263,144
              02)                                                                         141,936
              03)                                                                         146    524

                                                                                            $551,604













                                                                                                             7/15/70




                                                                                  Wisconsin    RMP
                                                                                  RM 00037 7/70.2
                            DEPARTMiEl4T OF HEALTH, EDUCATION, AND WELFARE

                                            PUBLIC HEALTH SERVICE
                             HEALTH SERVICES AND MENTAL HEALTH ADIVINISTRATION


        Date: Jill 17 1.01   l@)70

          to

             ProT.@)osal   --   "An   Educational   Program   to   Improve   'the    Care    of    the
       Subiect:
             F-i(Il)-risl,< !,'etus and Ne@,;born Inr'Fjnt"     Project   #19
          7'o: Acti g Director
             Reoioii6l Medical Programs Service

             I appreciate the       opportunity   to   review   this   Eiropo@al.    @-7e    are
             @.,-.ur..)poi,.,ting  a  number  of  similar  training  programs  as   well   as
             four   neonatal   intensive   care    unit    projects,    the    latter    with
             funds ava,,I@a'blE- for the first time in fiscal 1.97,).

             I have no c3.o@6t about the im ortance of increasing the
                                                   P
             @ui@,dei--stanclin,--f of tl-le neWoorn among physicians and nurses.
             III  reviewing  such  an  a-L3r)licz,,tibn  as  -LI-,is,  it  i.s  cyuite   possible
             that       :Ecaftil-@  of  reference  may  ].De  different  from  yours  since
                 r(,       f3-o@i@it the bacl-,jrouricl. of the                 prograi-,is    in
                      I function rather than the                      l@icd-ical Prc)@

                      education    in    itself    is    a-clesirac)l.e     objec  I       v7ould.
                                                                            t
             61.5o  !-)r@ interested in,l,-i-iowincj what br@nefitF,
             :C I.- C) m@ such  El  'O @l rot I  -v@buld  not  ,,@-.Tivc@  @-,'@i.@,consin high  p:t-i.orit@@7
                      i@t @-ap, a -f-a-,,,bra'olc- in:Fant rc,.ort-c-ility rate -Irf,,org the
             15.4   i.iifant deaths per 1,000 in 1967.            I-lo\,@@    this pro@-,ram
                      ii@,."P:rove the situation ')e@on@ J-u@l-ie           utioiis
             w
                           Iz) d
                 e. been rt',  ci  y  the  StDte                            -red:      years      is       not
             cl@ ar.    It  i',s  questionable  -that  i,,iuch  pro,:frc@-ss can  .:)c  made  in
                      and       neonatal       mortality        uiilc-.1@s        there        is        a        I)rog
             to  i,  @:)rc)ve.tliic-  maternity  cc-ire  of  the  Iii.      Costc-tric  patient
                                                                  9
             and       Nl,-iic@i       %-Tell       increase       t'@)e        avai@lz@bili.-Ly        of-        fn,,,iily        planning
                            The  ptog)@a-@n,r-@ay,be  hFirnr--)er'ed  if             lo
             maternity     patients  Oo  not  have  resources  to       meet       the        costs        of
             the                      care  they  need.

                   pzi,.,fe  on  program  evaluation  is   we a

             In  cohclLlsi@orl,   if  gains  in  fetal  and                 mortality   Fi-id    in
                                                                                     rbviii@-@  such
                               ..III-it  rates  are  among                  for  ID.P
             a  p r  -p,,) s,-, 1  i@ n  P, e.,@ i@ o n a I  i@l@- d, i c a 1.  1) i- o@- I r Fl i-Li !-J. r@  a I,:) p Ia. t 1. c@  n  d
             r)   t e,  ri to    to             a  favor@@bl.(@

                    A


                       J.

                                t     c,i