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                                                                                                                  i  ? '
                                                                                                                  :I                                       !!  I   I
                                                                                                                  :  I I                   I               I   1   I
                                                                                                                  I!III @. Ili41 !I I ii ii II i !! I!!I 1 ,Iiiiiii  !Ili III!
                                                                                                                          *EOO   1            82*





                                   REGIONAL MEDICAL PROCRAYS SERVICE
                       SUMMARY OF AN OPERATIONAL SUPPLEIENTAL APPLICATION
                                      (A Privileged Communication)


             ARIZONA    REGIONAL    MEDICAL    PROGRAM                  RM 00055  5/71
             University   of   Arizona   Coll,ege   of Medicine         April.   1971    Review    C6mmitt6e
             Tucson, Arizona  85721
             Program    Co2rdinator:    Dermont     W. Melick, M.D.

             Requested-  Direct Costs
                                  02 (6 mo.1          0.3                     05 (6,mo.)         TOTAL     -
             Core                   $1@56,650         @0-            -0-        -0-           $      156,650
             5EiServ. Areas)         37,475           $157,932   $209,191  $108,684               511,282
             CE(Phys.) #14           72,798          l@47,010        176,946    92,744            489,498
             Ariz. ECHO #15           1911762        324,044         204,064    69,081            791.,001

             Cont. Ed.
             Nur,,qinp, #16          31,034          .52,115_        5),'171    25,789            l@64,?33
               TOTAL                 $491,719        $681,171.      $645,514  $296,298            $2,114t762

             Current    Funding:    A    funding    history    gummary,is    appended.    The.current    2nd
                                    year is funded at $81.1.,191.e,.co.  for core and five projects.
             The commitment for the third'year is for $304,081 d.c.o. for the continuation
             for five projects only.   The Region is to submit a triennium application
             August 1971 and the core budget is estimated d.c.o.:
             01  -  $994,586;  04  -   $1,067,242;   and   05   -   $I,.I'23,561   (total   -   $3,185,389).
             Geography7pemokraphy:   The   ARMP   serves   the   entire   state   of   Arizona,    6    !Ian
                                          area of 114,000 quare miles and a population of
             1,741,000.  The state is bordered by California and Nevada to the west,
             Utah to the north,.Nev Mexico to the east and Mexico to the south.

             Medical       facilities:
             1)   University   of   Arizona   Medical   School   will   graduate   its   first   class    in
             1971.;   2)   seven   schools   of   nursing,   two   of   which   are   baccalaureate   degree
             programs; 3) five schools of medical technology; and 4) six x@ray technology
             facilities.   Medical    manpover    includes    2,120    physicians    (132    per    100,,OOO
             population); 241 osteopaths, and 5,000 nurses @@348/100,000).




            Arizona T4P                      -2-                    RM 00055  5/71


                                                              the Governor a ppointed   a
            Backp,round:  The ARMP began in Spring 1966 when
                         steering committee headed by  the  Dean  of  the  Medical  School.
            The initial grant application was  submitted  December  1966  and  support  for
            pl,anning was authorized for two years and three  months  beginning  April  I
            1967.  The Dean of the Medical School served as part-time program coordinator
            until September 1567 when the current  coordinator  was  employed  on  a  full-
            time basis.  Due to delays in the review and funding of the Region's
            operational program, the planning period was  extended  by  nine  months  to  a
            total of three years.   Planning awards d.c.o.:   01 - $119,045; 02 - $409,108;
            03 - $375,209; Total - $901@,362.   In June 1968, the  Region  submitted  an
            operational. grant application for support  of  a  pulmonary  disease  project.
            Based on the' findings of the August 1968 site  visit,  the  November  1968
            Council recommended that the application be returned for revision.
            In May T969 Council considered the initial operational application.       As
            recommended by Council, a site visit was made  that  same  month  to  assess
            the Region's operational capability.    The  application  requested  support
            for core staff activities and six projects.  The  site  visit  team  was  greatly
            concerned about the dominating needs of RMP in Phoenix and periphera    I  areas,
            and the contrast in the Region's plans  to  concentrate  its  headquarters  near
            the Medical School in Tucson.   Regional problems noted included:     1)   need
            for better health  care for the minority croups (I,?6,000 Indiana - 87.  of  the
            population and 187,000 Mexican-Arnericans    11% pop.);. 2) the  State  Medical
            Association's apparent disinterest in RMP;  3)  the  medical  school  had  only
            recently begun and could no t assure immediate strong support;  and  4)  75%  of
            medical service activities were in Maricopa County (Phoenix).     Of   1,650
            physicians in the State, 55% are in the Phoenix area and 3M.    in   Tucson.
            Osteopaths are the primary health care providers in a number    of    counties.
            Sixty nercent of the hospitals in Arizona have @ess than fifty beds.      There
            was some concern about@.@ the bylaws that provided the Dean  of  the  Medical
            a.chool with the authority to appoint the Regional Advisory Group.    Tne   site
            visitors nointed out that the bylaws were not explicit regarding the Regional.
            Advisory Group responsibility in appointment  of  its  members  and  approving.
            applications.  It was also"believed that  the  evaluation  capability  of  the,
            Region should be strengthened by acquiring  the  services  of  a  specialist.
            Impressions of staff leadership were favorable.    Although  there  were   some
            majo r problems, the team believed there  was  adequate  evidence  that  the
            ARMP was ready to  assume  operational  status.  The  visitors  were  convinced
            that further planning would not add  to  their  capacity  for  implementing  an
            operational program.
            Followi-rg_ approval by the August 1969 Council, $821,521  (d.c.o.)  was  awarded
            the first year for Core and five projects.    During  the  first  year  Council
            recommended non-approval action II  for  four  proposals;  Nutrition  Care,
            Education in Coronary Care,  Community  Education  for  Nurses,  and  Long-term
          @cT(i c a t ib-n fo       In I i gl, tIof  Councti"s  dis7a"rovat  o@-e  Tatter  three
            and their suggestions, the Region  redeveloped  a  program  for  coronary  care
            training ohich will ultimately involve five projects.     Two of these,  #11  -
            Continuing Education for Nursps and #12  -  Postgraduate  Courses  anO  Seminars
            for Pny4,;icians. Hospital Personnel and Trustees @,ere approved by the  July  I
            Council. 'rut not yet funde@.




           Arizona   RMP

           The second year continuation application for $842,125 d.c.o. for core        'and
           five projects was reviewed by RMPS staff in December 1.970 and upon their
           recommendation, $811,191 d.c.o. was awarded,  The broad goals were essentially
           the same as originally stated, but the 102 (1971.) objectives were diffuse.
           Staff expressed hope that the objectives (long and short-term, data-based,
            nd priority-oriented) will be better presented in AR triennium application
           Submission to RMPS August 1971.  Staff also expressed concern that the
           half million dollar core is directing most of its energies into development
           of projects for which there will be insufficient RMS support.  It was
           believed that there would be wisdom in the Region's reassessment of its
           operations in relation to priority needs and current available resources.
           In  light  of  federal  funding  restraints  some  core  activities  miIght be
           appropriately redirected.  A copy of staff comments and recommendations to
           the  Acting  Director,  RMPS  is  appended.
           Goals Otiectives and Priorities as described in the recent second /e@r
           continuation application:
           The goals and objectives are essentially the same as previously stated,
           but have been restructured with more detail and time frames for management
           monitoring.  Goals in terms of core staff and projects are as follows-
                   1.  Develop Adequate Health Manpower Res   ources.
                       A) Update the knowledge of Health Professional,s
                       B) Increase the number of Health Professionals
                       C) Innovative use of manpower
                       D) Increase tt, e opportunity for upward mobility of
                          Health Personnel

                 l@i.  improve Community Health Programs.
                 111.  Develop Cooperative Relationships Among Health-Related
                       Organizations in Arizona.
                  IV.  Have the Necessary Financial Organization Support to
                       Accomplish the ARNP Objectives.
            The   102  objectives are related to the following critical health issuer,,:
                    1. Gap between  new  biomedical  knowledge and its application to
                       patients;
                    2. Availability and accessibility of health service;
                    1. Health needs of tne poor, children, migrant workers and
                       Indiana;

                    4. Inner-city health problems;

                    5. Shortage  of  health  manpower.






                                                                  RM  00055   5/71
           Arizona PMP                   -4-

                                                                ject #4 - Con    uin
           Priority ranking for the second year:  Core first, Pro
           Education for Nurses second, Project #3 - Chronic Pulmonary Disease third,
           Proj'ect #6 - Cardiopulmonary Resuscitation fourth.$ and Project #5 -
           Recruitme                                  Service last.  Approved
           unfunded                        e present application are  not  ranked.
           A five-year long-range plan is to be fully described in the triennium
           application due August 1971.
           organization Structure and Processes:  The organization of the ARMP remains
                                                 essentially the same.  The 17 RAG
           members are appointed by the Dean. The RAG elects its  Chairman,  Vice-
           Chairman and five man Executive Committee.  The Chairman and Vice-Chairman
           serve the same offices on the Executive Committee.  Changes in the bylaws
           as amended March 1970 expanded the RAG term from two to three years (may
           be reappointed for two additional terms) and include a provision allowing
           the RAG to delegate to the Executive Committee responsibility and final
           authority for final approval of applications.  The Executive Committee also
           serves as the Review Committee.  Thirteen committees (7 categorical and
           6 area or ad hoc) with 189 members are utilized by the Region.  Relation-
           ships of the RAG with other health groups includes the CHP 314-A Agency,
           Arizona.Heart Association, Arizona Division of the American Cancer Society,
           and Indian Health Service.  The RAG Chairman is President of the Arizona
           Medical Association.
           Arizona law requires that all Regional Advisory Group members serve on
           the',Advisory Council of the Arizona Health Planning Authority 314-A.  To
           permit CHP flexibility in appointing the required 51% consumer representation
           to the Council, the RAG size and number of consumer members have been kept
           to a minimum.  CHP has not been included in the ARMP review process.   There
           seems to be evidence of tie-,in with professional resources including 314-B
           Agencies.
           Subregion activities will be undertaken as necessary, i.e., pLoject #16
           -nursing education, Indian 'reservations, model cities, continuing education
           service areas, etc.  The overall strategy, however, will Ie -region--Nvile
           Core:  According to the 02 continuation application, much of the projected
                  core.activities revolve around the submission, approval and funding
           of several- new Drojects.  Projects being developed include home dialysis,
           multiphasic screening and rheumatic fever, cate orical disease workshops,
                                                          9
           dial access, pediatric conferences, physician assistants and registeries.
           Planned core activities include educational programs for physicians and
           allied he alth professionals; efforts to train indigenous workers for model
           cities and neighborhood health centers; efforts for enactment of state
           legislation to legalize physician assistants; plan for state rubella
           vaccination program; assistance for further development of Area CHP in




             Arizona Ry?                                                 'PM  00055   5/71


             the northern area,  Phoenix  and  Tucson;  continued  studies  for  planning,
             including a  survey  of  health  manpower  and  continuation  of  "checklist"
             20th century  books.  A  notable  objective  is  the  cooperative  arrangement
             with Maricopa 'ounty  CHP  Council  to  develop  a  proposals)  for  multiple
             funding of health  programs  for  low  income  consumers  comprised  of  many
             Mexican-Americans and  Indians.  An  01  year  objective  no  longer  alluded
             to: "explore  the  feasibility  of  having  all  health  continuing  education
             -programs brought within the  organized  system  of  education  in  Arizona."
             Project  Program'.Status:  When  reviewing  the   continuation   application,
                                        staff was favorably impressed  by  project  4k4  -
             Continuing Education in  Nursing  Care  of  Patients  an  outstanding  program
             with a record of  success.  This  activity  existed  in  a  limited  fas  ion
             prior to RMP  support.  The  other  projects,  all  education  oriented,  had
             been operational for only a few  months  and  many  were  late  tool.ing  up.
             It was believed that a better assessment cat  be  made  at  the  time  of  the
             initial triennium review in the November 1971 cycle whet more      .  meaningful
             progress data should be Available.
             Present A@olitation:  This it a,request for supplemental support for core
                                     staff for six months and support for four new projects
             for three years.
             Core-Activitieg - The sum of $148,982 is requested for          Requested
                                additional core staff support to work        Onl,y  6  Months
             in the areas:  1) development of comprehensive health           $1.56,650
             services primary focus on prevention and early detection;
             2) accelerated health manpower and facilities; 3) further      integration    of
             ARNP program activities with those  of  the  CEP  A  and  B  agencies,  Model
             Cities program, OEO  and  other  public  and  private  heal.th-related  program;
             and, 4) additional support and coordination of operational project activities,
             and increased responsibility delegated to the Region by RMPS.  The supple-
             ment proposes adding 11 professional and 7 clerical positions, for a total
             staff of  58  (41  professionals  and  semi-professionals,  And  17  clerical
             personnel).
             The request includes $7,668  for  continuation  of  the  pilot  work  on  the
             dial access program which began in the previous year.  A project proposal
             for this activity is planned as part of the triennium application submission
             to RMPS August 1.971.
             The proposed core supplement increases the current annual level to
             $816,600 d.c.o.
             Project #1.3 - A Broad Continuing Education Pro           Requested Ist Period
                            For-Physicians in Arizona - Development         6 Months
             of  Continuing  Education  Service  Areas.  This  is  a        $37,475
             companion to Project #14 - C6nt   inuing_Educatioh for
             Physicians.  Proposed  by  the  University  of   Arizon.a College of Medicine,
             this is a  project  to  organize  15  sub-regional  continuing  education  areas
             to  insure  formal  education  opportunities  to  all  Arizona  physicians.  The
             areas wil:l be organized  through  the  coordination  and  assistance  of  the




                 Arizona                            -6-                    RM 00055  5/71,


                                                                                A project
                 CESA Program Coordinating Committee for Medical Education.
                 directo' and the Committee are to be appointed  by  the  Dean  of  the  Medical
                       r
                 School. The focal point for each CESA  will  preferably  be  a  hospital  and
                 each area will have a  local  functioning  committee.  Each  CESA  focal  point
                 is to have teaching  facilities  and.equipment.  The  local  committees  will
                 be responsible for working with  fellow  physicians  in  the  development  of
                 workshops and conferences to meet their needs.  The Committee and four
                 CESAs are to be functionable within  six  months,  ten  CESAO  within  eighteen
              ,.months and all fifteen  within  the  third  project  period.  The  educational
                 activities will be provided through the resources of Arizona heal.th
                 organizations, i.e., the  University  Colleges  of  Medicine  and  Continuing
                 Education; ARMP; and Arizona  Medical.  Association.
               ,The project will be monitored and evaluated by project personnel with
                 assistance from ARMP core staff, the CESA Committee and participating
                 physicians.  Evaluation  procedures  will  include  physician   self-evaluation
                 questionnaires, comparative patient management problem scores and
                 comparative chart audits.
                 The applicant assumes that the project  will  be  supported  by  the  Medical
                 and Osteopath Associations, and fees after cessation of the grant.
                 Second Period,             Third Period               Fourth  Period  (6  mos.)
                    $1.57,932                 .$209,191                     $108,684

                 Project  #14  A'Broad Continuing Education Program      Requested  First Period
                               for Physicians in Arizona Workshops,             6 months
                 Conferences and  Other  Pos@raduate  Medical   Educa.tion.      $72,798
                 Fro-posed by the University of Arizona Medical School, this
                 is a companion project to #13 CESA.  The purpose of this project is        to
                 deliver the  continuing,education  to  physicians  through  the  fifteen  CESAs
                 on a structured and regular basis'.  The proposed program is based on
                 responses to a survey of physicians, Medical Association resolutions,
                 and 18 workshops conducted in 1970 by ARMP.
                 The project director will  serve  on  the  CESA  Coordinating  Committee  and
                 will work closely with that project as well  as  the  each  chairman  of  the
                 1.5  local  committees.  Designated  disease  categorical  coordinators,  all
                 of the College of  Medicine,  will  have  responsibility  of  development  of
                 specific curricula in  response  to  wishes  of  the  local  committees.  The
                 workshop conferences will be physician oriented, but allied health
                 personnel will be welcome, and when appropriate they will be util.ized
                 as  faculty,
                 Topics of snecial value to  practicing  physician  will  be  reproduced  into
                 slide cassette tapes and copies distributed to al.1 of the CESAS.  Selected
                 cassettes produced by other health organizations will also be distributed.
                 Workshop projections: 17 during the  first  six  months,  40  in  1972,  53  in
                 1973 and 30 in first six months of 1974.




              Arizona RMP                     -7-                    RM 00055  5/71

              Effettiveness of the workshops willbe  determined  by  project  staff,  ARMP
              staff, the CESA Coordinating Committee, local medical education committees
              and participating physicians. Information  upon  which  evaluation  will  be
              based includes number of workshops, attendance, post workshop suggestions
              by attending physicians, periodic  questionnaires  to  physicians  attending
              and those not attending, and the extent CESAs develop programs bevond
              the workshops.  An attempt will also be made to evaluate behavorial
              changes.
              With regard to continuation after three years of ARMP support, the applicant
              anticipates that some financing can be assumed by the College of Medicine
              through appropriate legislation.  Other means of future funding might
              include assessment of the recipients and their organizations.
              Second Period              Third Period              Fourth Period (6.mos.)
               $1.47,010                   $176,946                    $92,744

              Project #15 - Arizona Evidence for Community Heal.th Organization

              Conjoint funding proposed
                             01 (6 mos,@      02         03     0  (6 mos.)      TOTAL
              RM.P            $193,762     $324,094  $204,064    $ 69,081     $    791,001

              State & Local
              Health Depts.       -0-        81,024    249,41.2    161,190         491,626

              Total Direct
              Costs           $193,762     $405,118  $453,476   $230,271        $1,282,627
              Proposed by the Arizona Department of Health, the purpose of    the project
              is to provide for a unified system  for  acquiring  Arizona  population  health
              data. Similar to a system used in  Michigan,  a  pilot  test  was  accomplished
              in Tucson (Pima County) and Phoenix (Maricopa County).  The project provides
              for a statewide expansion and  incluees:  1)  collecting  data  about  environ-
              mental and personal health conditions; 2) anal.ysing the data and converting
              it into readily usable information  for  both  technical  and  non-technical
              "ersons: 3) providing a mechanism for distribution of data at all levels;
              and 4) provision for education to ensure use of data.
              This system including 14  county  health  department  subsystem,  wil-I  afford
              information necessary to planning development and evaluation to the State
              Health Department agencies including 314 (A), two  CHP  31,4  (B)  agencies,
              14 county health departments, RMP and other health organizations.  The
              Commissioner of the Arizona Department of  Health  will  appoint  a  project
              director and advisory committee.consisting of representatives of the




             Arizona                                                  RM 00055 5/71

             participating organizations.  Personnel already trained in the two pilot
             counties will be used to train personnel in the remaining twelve counties.
             The work projections are based on the Governor's designated six planning
             areas.  Projections for implementations:
                                                 @egin                          complete
             Area I & II                         711/71                         1/1!73
             Area III                            6/i/72                       1111   74
             Area IV & V                         7/l/7)                         1/l/74
             Area VI                             6/1173                       *.11/1/75

                   Dates beyond the RMP funding relate to continuation
                   of implementation through local support.
             Effectiveness of the project will be determined chiefly be frequency data
             is drawn upon.   Some random samples of the "p6rson to person" acquired survey
             information will be rd-evaluated for accuracy.
             The Arizona State, Department of Health will request funding from
             the State  legislature  to  begin  mid  1973.  Continuation  of  the  project
             after cessation of RMP funding seems to rest with the legislative process.
             Most of the budget'is for personnel.  Of $122,002 for personnel the first
             six months, $73,011 is for positions (most already filled) for the Pima
             County and Maticopa Health Departments.      $40,618 is budgeted for personnel
             in the State Health  Department  and  $15,142  in  the  three  county  health
             departments of Gila, Yuma and Pinal.
             Second Period                   Third Period                 Fourth Period (6mos.)
               $324,094                        $204,064                         $69,081
                                                                         Requested First Period
             Project #16    Continuation   Education for Associate             Six  Months
                            Degree and Diploma Nurses.  Proposed by             $31,034
             the Northern Arizona University, the project aims to make
             available 30-40  hours  of  continued  education  to  each  registered  nurse  in
             Arizona by 1976.  The project aims include the involvement of junior
             colleges in providing nursing continuing education opportunities in
             five non-metropolitan  county  areas  with  a  focus  on  Indian  Health  Service

             nurses.
             Work  projections:  1)  annual  10-day  workshops  at  the  Northern  Arizona
             'University for about  15  faculty  members  of  associate  and  diploma  nursing
             nrog-ams- 2) four annual workshops in non-metropol.itan areas, utilizing
             resource   faculty selected at the  workshops  for  faculty;  and  3)  a  3-5
             env course at the close of each  project  year  for  25  of  local.  workshop
             narticipents to specifically hel.,p them develop additional. staff and leader-
             ship cann'@-ilities.  Consultat ion services will.  also  be  offered  to  nurses
             in the tarzet areas.




                                                                 RM 00055  5/71
            Arizona RMP

            The section of the narrative dealing, with the evolution of the nroject
            allu(ies-to two other nursing continuing education projects approved by
            ARMP, one of which is ongoing.  However, specific relationships are not
            spelled out.
            Evaluation, will be based on the numbers of:  1) nurse participants;
            2) nurses assigned positions of more responsibility as a result of the
            project education activities; and 3) participating agencies and individual
            requests for consultation.  Evaluation of effectiveness will include pre-
            an4 liost-testing, assessment by faculty during consultation, course
            evaluations by participants, self-evaltiations, post follow-up evaluations
            1-Y employer and supervisors and nursing audits.  The University of Arizona
            Dopartmpnt of Systems Engineering will be utilized in evaluation on a
            sub-contract arrangement.
            The applicant anticipates cost-sharing by cooperative arrangements, and
            even state legislative support, after cessation of the grant.
            Second Period                Third Period           Fourtn Period (6 Mos.)
               $52,135                      $55,373                $25,789
























                                                                        GRB/?/5171




                                                                                         RM 00055  5171
            Ari7one RMP
                             DEPARTMENT OF HEALTH. EDUCAT',ON. AND WELFARE
                                              PUBLIC HEALTH SERVICE
                                             -S AND rV.ENTAL HEALTH ADMINISTRATION
                              HEALTH  SERVICR


               December 17, 1970
     Relit)? to
      Attiz of.,
                                                    of  Arizona Regional Medical Prograin's
               Staff Review December il, 1970@
      S@i,jecl: second year continuation applications 5 G03 RM 00055-02

         TO:   Acting Director
               Regional @edical Programs     Service

     Thru:     Chairman  of   the   Month
               Acting Chie     @epional    Development    Branch
               Actino Chi&              ee@@6w Branch

                   est:  This   is  A  request  for  $842,125   d.c.o.   which   includes   the   com-.
                          riitited  level   $811,191   and   $30,934   carryover.   Uiiexpended   funds
               at the close of the current period are estimated at $30,957.
               Recommendation:  Approval  in   the   amount   of   the   commitment   $811-191 d.c.o.
                                   The   recommendation   includes   advice   to   the   Region   about
               the concerns of the reviewers.   Staff also believes that consultation
               a  d/or  assistance  at  an  early  date  Rtay  be  helpful  to  AMIP  prior  to   sul)-
               mission  of their initial anniversary review application.
               The use  of carryover or new funds does        not  seem   justified   at   this   time.
               In some  instances, i.e.,     legislative backup assistance, utilization of
                       g  o  e  s  'aff  and/or  rebud,,eting  w
               existi'n  c   r   t                             ould   seem    appropriate.
                                        Basis,for the Level    Recommended
                                                    Reqfieste(                           Recommended

                                   Commitment       La      over        Total
               Core                    $503,300    1/      $30,184      $533,484               $503,300
               #2  Med..  Lib.          36 31  211             -0-        36,211              36,211
               #3.Pulm. Di.s.          -112,000                -0-       112,000                112,000

               #4 Con t.   Ed.
               Ntir'sing  Care          65,807               -0-          65,807              65,807

               95 Recruit. &
               Cont.'d   Educ.
               Social    Ser..          57,5'00                750        58,250              57,500
                                                                               3              3 6_@l  3
               #1 CPR                   36.373
                                       *811,191            $30,934      $842,125               @811,193



              Ari7nnm   RMP                                                RM   00655   5171

              Harold Margulies, M.D.                                    December ',-7,  1970


              1/    $10,794 project evaluation
                    1011590 support of "dial-a-tape" T)il.ot T)ro@,,ram  untiL  submission  of
                            the project to RMIS 2/l/71. (start 7/l/71)
                      8,800 health planner and writer (6            (cooperative  effort   with
                            State Ilealtli Department, C'flll A & 13, and County Hc!altll
                            Departments)  backup  for  legislative  approval  of  the   Arizona
                            Health Data Service
                    $30$184

              General  Comments:  The  broad  goals  are  essentially  the  same  as   previously
                                   stated.  The  102  (1971)  objectives  enumerated   and   soared
              to  completion  dates  are  diffuse.  Hopefully  the  objectives  .(long  and  short-
              tem,, data based  and  priority  oriented)  will  be  better  presented  in  the
              AR triennium application submission to RIMPS August 1971.

              The organization is  about  the  same.  Arizona  law  requires'  that  all  ARMP
              RAG members serve  on  the  Advisory  Council  of  the  Arizona  Health  Planning
              Authority (CHP 314-A).  To permit CHP flexibility in appointing the
              required 51t consumer  representation  to  the  Council,  the  RAG  s-Lze  and
              number.of  consumers  has  been  minimized.  The  RAG  members  are  appointed   by
              the Dean - a matter of concern to previous reviewers.  The bylaws were
              recently amended to increase  RAG  terms  from  two  to  three  years  (may  also
              be reappointed for two additional years).  The Executive Committee may act
              for  the  RAG  in  the  interim  between  meetings.  Thirteen  committees  (seven
              categorical and six area or ad hoc) with 189 members serve the Region.
              The review process includes the utilization of categorical committees,
              and review by the  Executive  Committee  prior  to  final  action  of  the  RAG.
              CHP is  not  currently  involved  in  the  review  process.  A  major  concern  of.
              future RMPS visitors  wil.l.  be  organizational  effectiveness  including  thne
              RAG's  actual  role  in  regional  affairs.  Adequate  technical  review  as   part
              of the review  process  will  be  essential.  Mutual  reviews  and  critiques  o@'-
              goals, objectives,  plans  and  specific  proposed  activities  by  A@IP  and  C14P
              might be beneficial.

              The core staff includes 21 professionals (7 part-time) and 8 administrative/
              clerical  positions.  Five  of  the  professionals  (1  part-time)  and  one   office
              supervisor are budgeted-for the Phoenix Office.  One professional (20% @MP
              and  80%  Coconino  County  Health  Department)  is  budgeted  for  Flagstaff,
              Subsequent to  submission  of  the  application,  ARMP  advised  that  all  four
              unfilled positions are committed.

              Curriculum  vitae  for  newly  employed  were  provided.  Job  descriptions   for
              newly acquired  employees  and  positions  to  be  filled  would  have  been  helpful
              to the reviewers.

              Staff express@d concern that the half million dollar core staff         is direct-
              ing most of its energies into development of Drojects for which          there
              will be  insufficient  RMPS  support.  It  would  seem  that  there  would  @e
              wisdom in  the  Region's  reassessment  of  its  op.erations in relat-l.on to





                                                                RM 00055   5171
           Ari7ona RMP



           Harold Margulies, M D.                                December 17, 1970


           priority.ndeds and current limited available resources.   In light of
           federal funding restraints, activities., including core, might be  aR2ro-
           priately redirected.

           With one exception, the current funded projects have been operational for
           only a few months. Many were late tooling up.  A  better  assessment  can
           be made at the time of the next anniversary review when  more  meaningful
           data should be available.  Staff was favorably impressed by  project  #4,
           "Continuing Education in Nursing Care of Patients    an outstanding
           regional program with a record of success.



                                                Liit er 'J. Says
                                                Public Health Advisor
                                                Grants Review  Branch


           Action by Director

           Initials
                                  -7e
           Date



           Attachments:
           1) Mr. Says', GRB, review comments

           RMPS staff who attended this review meeting:
           L. J. Says, GRB
           Jim Smith,, RDB
           R. D. Merck6r, GMB
           Teresa Schoen, OPPE
           Mary Asdell, CETB




                Arizona RMP                                                  R,4 00055  5/71


                                  REVIEW  AND  FUNDING   HISTORY   SUMMARY



                PLANNING
                lit Year                                  4/l/67-3/31/68                $119,045
                (Site Visited August 1-968)
                Cduncil:
                  1967 -  February
                  1.968 - May, November
                2nd Year                                  4/l/68-3/31/69                 346,125
                  02 Supplement                           1/l/69-3/31/69                  62,083
                                                               TOTAL   02               $409,108
                Chronic Pulmonary Disease Program       Application for "Earmarked Funds"
                                                        Disapproval with advice to resubmit
                03 Year                                   4/l/69-6/50/69
                  Extended with Funds                     4/l./69-9/30/69                117,208
                  Extended with Funds                     4/l/69-i,2/31/69               106,630
                  Extended with Funds                     4/l/69-3/l/70                   13,276
                                                               TOTAL   03               $375,209


                OPERATIONAL                               I/l/70-1.2/31/73
                 (Site Visited May l@969)
                  Countil:
                    1969 - May, August
                    1970 - March, July

                                                                            Direct Costs
                                                       Approved                                 oved
                                                        Period       Funded              Future Level
                Core                                   2 years      (01)    $503,300     (03)     -0-
                                                                    (02)     503,300


                #1   Checklist     20th
                     Century Books                     3 years    I/ Approved in principle with no
                                                                      additional funds
                #2 - Medical Library Network           3 years      (01)      39,233     (03)  $ 35,211
                                                                    (02)      36,211
                #3 - Chronic Pulmonary Disease         3 years      (01.)    139,988     (03)    120',OOO
                                                                    (02)     112,000




              Arizona RY.P                              14-                   RM 00055  5/71

              #4    Continuing Education in         3 years      (01)    51,895       (03)  $  84,118
                    Nursing Care                                 (02)    65,807
              #5    Recruitment   &   Continuing    3 years      (01)    32,621       (03)     28,379
                    Education  Social.   Service                 (02)    57,500
              #6    CPR                                          (01)    26,106       (03)     36,373
                                                                 (02)    36,373

              #7    Continuing    Education
                    Coronary Care                   Disapproval   with   advice to resubmit

              #8 -  Continuing    Education
                    for Nurses                      Disapproval   with   advice to resubmit

              #9   -.Long-Term   Continuing
                    Education  for   Nurses         Disapproval   with   advice to'resubmit
              #10   Nutritional Care                Disapproval   with   advice to resubmit

              #11   Coronary   Care   Continuing
                    Education  for   Nurses         Approval I   (unfunded)

             412.-  Coronary   Care   Post-gred@
                    Courses & Seminars for
                    Pbyicians, Hosp. Adm.
                    Personnel & Trustees,           Approval I (unfunded)



                         TOTALS
                                                                 (01)    $793,133     (03)   $304,081
                                                                 (02)  $811  191.

              I/ Supported through Core-- 01 year


                                      APPROVED  &  UNFUNDED   PROJECTS

                                                  (D.C.0)
                                   01                         02                  03
              #11             $ 7C,583                    $  77,405             79,988
                               ..74,812                      68,648
              #12                                                               70,640
                TOTAL         $151 395                    $146,053            $150,628




                                     Ari7ons     RMP                                  -11
                                                                                        Ali"' ZOINA
                                                                                                                                             -12/70
                                                                                                         c,rrc-nz                        '/-/o
                                     Program   Funding:                 --------- $     311,19',L        First Schedui@d AR ipplicatic'-',Auyuat  t971
                                     Approved for Ctrrent Year  -----
                                     Operating level i@ Current Year                                     Regior,'$ Optional plans:              iy
                                                                                $ 3 1 1,  19  I
                                     Recommended   Commitment   for    next    year --- s       304,081

                                                                                        r
                            COMPONENTS BY DISEASE CATEGORY                        COMPONENTS                               COMPCKEN-L; BY TYPE OF ACTIVI':Y
                                                                           ON-GOlt-"                              TRAlt@l@iG  AND   EDIICATI(-,N
                       HEART                                               ore--@',zO3,300                                 on-going          5
                            on-goinit                                                                                      .  0 Projects  _
                              # Projects             0                     #2 Lib.  Network                                Total-ss   307 891
                              Total SS               0                                                                     %                38%
                                                     0                        $36, 21 1
                            Approved/unfunded        2                     #3 Chr@  Pul.  Dis.                     __Ris@pr ved               4@
                              as     r                                        $ 112,000
                                                                           #4    Cont'd     Ed.
                       CANCER                                              Nursing         Care
                            on-going
                                Projects             4                        $65,807
                                                                                                                   DEMCCST@TION OF PATIENT CARE
                              Total SS                                     #5 Recruitment-                                 On-R.Oing
                                                                           & cont. Ed.                                      Projette
                              %     SS
                            Approved/unfunded                              Socia! Service                                  Total SS
                            Disappi                                           $57,500                                       SS
                                                                                                              1            Approved/tinfunded
                                                                           #6 CPR                                          Disapproved
                                                                              $36,3



                                                                                                              1    RESEARCH   &    DEVELOPITNR
                                                                              Nurses                          i            oil-going
                                                                              $76,583                                        Projects
                       KIDNEY                                                                                 I            Total SS
                                                                           #12 C.C- Poat-Grad i                            % SS
                            On-going                 0                        Ed. Phys. HOSP-                              p proved /un funded
                              # projects                                                                                   A
                              Total SS               0                        Adm. & Trustees                              Disaoproved
                              %   SS                 0                        @4 ql2 - Total
                            Appr oved/unfunded                                151,39
                              i$8    roved


                        RELATED DISEASES
                                                                                       QUEST                  I A-DMI-Nr----
                              *n-going                                     SUPPL.    RE                                    STRATION & PLANNING
                                # Projects                                    Core                                        On- P'Oin9
                                Total  $s         14                                                         T7,           @k Projects 1 ((,.ore.
                                %   Ss                                                                                     Total SS   503,300
                              Approvedlunfunded                                                                            % SS           6@%
                                as pro@d                                   #13 Coqt.                                Appro@ed/unfunded
                                                                        I.-Ser. Arei                                Disapproved
                         MULTICATI(.ORICAL                                      $37,4j
                                # Projects             3
                                                  15                             code. Ed.-
                                Total SS
                                % SS                                          Physicians
                       i      Approved/unfunded        3                        @72,798
                       ,@L.approvel
                                                                                 ECliO
                       1       GENERAL
                              on-P.Olne                                       $193i762
                                # Projects        1 (Core)
                                Total SS          503  00
                                                     62e
                                %  SS                                                       d.
                              Approved/unfunded      0                        Nurses of Assoc*
                              Disa                                            Degree & Diploma
                                                                              Programs
                                                                           -  .$31,034                -


                        * #1 Check list
                                20th  Cent.  Books
                                Approved & unfunded
                                is funded through Core
     le




                                                                                .(A   Privileged    CominLti-ii.catioli)




                                              SU@,4'MAY@Y OF RE\,IEIL j@NI) COI@;CLUSION     OF
                                                   tiPRIL 1.97i. REVIE@. COIIL@iTl@T-i,-,!,"


                                               AP,IZOI-Il@@  REGIC),@,AL  IIFI)ICAL  PPOGRA.@L
                                                         P@l 00055       5/71


                                     FOR CC-IIISI'DERATIO'Li BY IIAY 1971.      ADVISORY     COUNCIL


                   RE('$'),%Z'END,kTION:   Disappkoval of additional            Core    support    and    approval    bk
                                           projects with no additional funds.

                   YE.-t-lil                                 R E 9LJ EL,@'                                 FIJI\'Dli\'C-

                   02  (6 r@ios.)                            $491,71.9                               -0-
                   03                                              681,171
                   04                                            645,5-."4
                                                                                                      01-


                                                                $2,114,726                           -0-


                   LP@     U@E:   Tiie CoiTni:ttee noted that the current  level of                            of Arizona's
                                              is               (d.c.o.)@   of    which    $503,300    (62%)    is    for
                   Co@-(,     activities.     Tlie.present:     request     would            the annual cost of
                   core to r@iore than $F300,0,,',O,  nid slickil-d not be a-,,)proved.            Current        support
                   should   be    3deqLiate    for    ecirc,    activities              some  L)il@.-)t  work   on   the
                   di,-)I access pro-,rari,@.

                   The   Comin.;.ttc-e   also   recognized   the    concerns    tl@ct    staff    had    when    renewing
                   the second-vear continuation nppl.icat4@oTI:  that the objectives were not
                   clear and that core activities were preclot-ri-@n,),t:ely @)roject or-i-ent(!d.
                   C6ri-iiittee concurred. vii!-ii staff that there woul.d be i,7isdo,,ii in the llegioii's
                   reassessment   of   its    operations    rel    ti.vc-    to    priority    needs    and    resources,
                                     i@@          of 7-'dNi"-3s funding co.,.,.St)@.@iit,,ts -ILi7i fiscal  year  7  and
                   724   Also,  as reported l@y staff,  the-Rc!,o,4,on has planned a retreat in late
                    p i@i.   r,@el?s staff are to attend and may be helpful  in guiding the Regi.on.

                   Arizoi-,I'S,Prirnary    p-coject    tlirust    continues    to    be    training    ind     education.
                   The five currently funded pro3ects  include a library network,  chronic
                   pulmonary disease, nursing care,  sr@ciil service,  and CPR.                       Two       coronary
                   care training projects were approved, but unfunded.                        Tll@   present   ap-P.13.-
                   cation does not include i ra-n'L" list of all projector.

                   The projects presented represent noii-categoric-@ll ouireecl-i,l)rogra-,Is qnd
                   do relate to the Reoioiis broad goals.                 Correlztioii with ol)er.',tiTIc- objectives
                   -I,Yttl T.)riorities is not clear.        The two ContinLiinc, Ilclu,--ati.on                     for
                   Pl,,Isiciahs  (Projects'  13 and 14) are coritp,,@iiion pr(-j,,@,cts                 irti@L41-it be
                   co@!@t)].ned and accomplished for less costs.                The "Arizona Evidence for
                   Cor@,@iii.inity Iliealth Orgaiiizctiori" project ip'15 may etil,-iance







             ARIZONA DIP                      -2-                 RM 00055  5/71

             and evaluation efforts @,?i-th health departments CHP a@,Lnc,.es end others.
             The "Continuation Education for Associate Degree and Diploma Nurses"
             project #16 has a much needed focus on Indian Health.

             Comr.qittee noted that the May 1.969 site visitors recognized that one of
             the Regionts problems @,7as need for better health care for the minority
             groups (136,000 Indians - 8% of the population and 187,000 llexican-
             Americans - 11% pop.).  The question arose as to the Re-ion's current
             involvement and plans in this direction.

             In conclusion the Corirtil.ttee did not believe expansion of core is justified.
             Projects' may have merit but additional funds at this time are not vyarrqnted.
             The Region's trienium application is due August 1, 1971 and will include
             a site visit to examine their total proEritti, progress ?nd capability.



































                                                           Pkl'-PS /CRB
                                                           4/21,/71.








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


           BI-STATE REGIONAL MEDICAL PROGRAM                     RM 00056  5/71
           (Washington University)                               April 1971 Review Committee
           607 North Grand Boulevard
           St. Louis, Missouri  63103


           Program Coordinator:  William Stoneman III, M.D.
           This application requests supplemental funds to support two new operational
           projects.
           This Region is currently funded at $945,233 (direct costs)  for  its  second
           operational year (which is an 11-month period)  ending  September  30,,1971.
           Due to RMP fiscal 1971 (and 72) apportionment this total in  to  be  reduced
           by $60,314. For this year the Region received  indirect  costs  of  $305,046
           on its $945,233 which represents an average indirect toot rate of 32%.  The
           Region will submit its Anniversary Review Application in time for review
           during the July/August 1971 review cycle.

                                    REQUESTED (Direct Costs On v)

           Project     Title       lot  year    2nd  year    3rd  year      Total
           #15 - Public Education    $@5,390      $20,988      $15,000      $71,378
           Program on Harmful
           Effect of Cigarette
           Smoking
           #16 - Develop a Model      16,750       15,850       15,850       48,450
           for Testing Physician
           dontinuitm Education
           TOTALS                    $52,140      $36,838      $30,850     $119,828

           Staff hat conducted its review of the  Regions  application for  second-year
           .operational funding. While there were several  programmatic  and  budgetary
           Issues identified by staff, (see Addendum page) because of the nature of
           this application (operational supplement) the Region did not relate to these
           concerns.  It can be assumed that information relative to the issues.will be
           included as a part of the total program review at the time the Anniversary
           application is considered.





         BI-STATE REGIONAL MEDICAL,PROGRAM            2,-            RN 00056  5/71


                                         FMINI;   HISTORY'

                                         Planning   Stage
         Grant Year                         Period                  -Funded (Direct   Costsi
              01                      4/l/67  -  10/31/68 (19 mO            $495,395
              02                     11/l/68  -  10/31/69                   443,625


                                        Operational Stage
              01                  .7/t/69 - 10/31/70 (16 Mo. )            $1,094,077
              02                  11/l/70 - 9/31/71  (Ij Mo. )              945,233   (of which
                                                                                      $64,293
                                                                                      is carryover)

              02 Year Listinit of Funding  Status  of-Core  and  operational   Prolects
                                              in Bi-State RMP
         Project                        Title                         Amount Supported (d.c.)
                                                                      Through   9/31/71

                                                                            $489,296
              0                         core
              2                         Cooperative Regional
                                        Radiation Therapy Program           .118,564

              4                         A Comprehensive Diagnostic
                                        Demonstration  Unit  for  Stroke       46,037
              5                         A  Nursing  Demonstration  Unit in
                                        Early Intensive  Care  of  Acute
                                        Stroke                                 55,690
              8                         Cooperative Regional Information
                                        System for Health Professi  I ons      39,748
              9                         Health  Surveillance   Education
                                        and Care Accessibility for
                                        Idw-rent projects                       1312605
              12                        C.C. Training Program for
                                        Nurses                                 64,293 a/
          a/ carryover funds                                  TOTAL            $945,233
            This amount is to be reduced by $60,314.  The     breakdown of the reduction is
            not available at this time.







          BI-STATE REGIONAL MEDICAL PROGRAMS        3 -           RM 00056  5/71


          The Region has a fairly well-balanced overall program between Heart Disease,,
          Cancer, Stroke and Multi-Categorical activities.

          B*ckground Information

               1.  Population:  4,9000,000 (estimated)
                   (a)-Urban     80%
                   (b) Non-White  9%
                   (c) Median age  31.6%

               2.  Medical Schools
                   (a) Washington University
                   (b) St. Louis University
                   (c) Southern Illinois (To open in 1972)

               3.  Physicians  -  5021

               4.  General   Hospitals - 178  22,000 beds

               5.  Geography
                   (A) 66 Counties  in Southern Illinois
                   (b) 42 Counties  in Southeastern Missouri

                               SUMMARIES OF NEW OPERATIONAL PROPOSALS

                                                                        Requested let  year
                                                                            . (d.c.)_
                                                                           $35,390

          Proposal #15 - To Provide Coordination for Public
                          Education Programs in the Bi-State
          Metropolitan Area on the Harmful Effects of
          Cigarette Smoking.  The Bi-State Inter-Agency Council on Smoking and     Health
          for the Greater St. Louis area (includes 30 health or health interested agencies)
          requests through the Bi-State Regional Medical Program a  total  of  $71,378(only
          direct costs are requested)to plan and implement this proposal for a three-yeat
          period. The program is to be physically based in the offices of  the  St.  Lou  a
          Medical Society (without charge to the grant).  The  program  was  reviewed  by
          the Region's Cancer Committee, the Scientific and  Educational  Review  Committee
          and the Regional Advisory Group.  In the latter group it received a priority
          rating of 250 on a 100 to 500 scale.


            The program has a tingle objective which is to improve  coordination  of  the
            Bi-State Metropolitan area (six Missouri and Illinois Counties) efforts in public
            education on the harmful effects of smoking.  According  to  the  application
            this proposal will advance the Region's strategy in that the program has strong
            categorical disease application,as well as professional acceptability and







          BI-STATE REGIONAL MEDICAL PROGRAMS            4             RM 00056  5/71


          consumer appeal.  Bringing  education  to  the  public,  especially   the   younger
          public, on  the  harmful  effects  of  cigarette  smoking,  the  proposal  will  also
          bring visibility to  Bi-State  RMP  and  heio.define  the  program  as  a  unifying
          factor in the Region's health care planning.
          Essentially  support  is  requested  to  provide  for  a  full-time  program  coordi-
           nator and  secretar'  plus  the  usual  expenses  (excluding  rent)  who  will  survey
                               y
          existing activities and resources and then develop and implement a coordinated
          anti-smoking  public  education  plan  for  the  area.  A  means  of  evaluating  pro-
          gress is  outlined.  Basically  its  success  will  be  measured  in  terms  of  local
          support  which  the  program  receives.  While  the  primary  program  target  area  is
          Greater St. Louis,  the  program  will  be  made  available  to  interested  groups  in
          other parts of the region.  'The proposal i  presented with a descending
          scale budget.  The second year request is :olely for the support of the coordi-
          nator and secretary, while  the  third  year  requests  a  single  salary  for  the
          program  coordinator.  The  Region  has  been  given  reasonable  assurance  that   as
          the program matures, its costs will be borne by other agencies.

          Second Year
          $20,988                                                        Third Year
                                                                         $15,000

          Proposal #16    To DeveloR a   Model for Testing Effectiveness                Requested
                          of Physician   Continuing Education Programs in             lst  year-
          Terms  of  Patient   Management.                                              $16,750
          The  Bi-State  Region   requests a total of $48,450 (only direct costs are requested)
          to  conduct  this  activity  for a  three-year  period.  The  proposal  was  first   re-
          viewed  by  the  Region's  Continuing  Education  Committee  which  recommended   some
          changes.  These  changes  were  incorporated  and  a  second  review  was   conducted
          by  the  Scientific  and  Educational  Review  Committee.  The  proposal  was  then
          presented  to  the  Regional  Advisory  Group.  During  its  initial  review,  the  RAG
          recommended that action be with@eldi pending approval of the plan by the
          Illinois and Missouri State Medical Association (Society).  The Missouri State
          Medical  Association  approved  and  commended  the  innovative  idea.   The   Illinois
          State  Medical  Society  recommended  that  the  proposal  be   approved.   Following
          this, and upon re-review, the RAG unanimously approved the program with a
          priority rating of 150, on a 100-500 scale.  This is the highest priority given
          to any Bi-State proposal to date.
          The  program  has  two  objectives  which  are  to:  (1)  Determine  the   feasibility
          and acceptability to practicing physicians of an experimental system for
          ascertaining  patterns  of  patient  management  from  hospital  record   analysis.
          (2)  Test  the.usefulness  of  such  patient  management  analysis  to  faculty   and
          local physicians in planning continuing education programs.
          Three hospitals  and  their  medical  staffs,  two  in  Illinois,  one  in  Missouri,
          have  presented  formal  evidence  of  their  willingness  to  have  hospital  charts      1.




   "I&I-STATE REGIONAL MEDICAL PROGRAMS             5 -            RM 00056  5/71
         analyzed to determine baseline physician performance data on  selected  diseases
         and in selected clinical hospital procedures.  Using this  information, problem-
         oriented Continuing Education Programs, with each community identifying the
         fields of clinical practice in which it is most interested, will  be  developed.
         The proposal incorporates not only local physician design of an  education  pro-
         gram but also a mechanism for measuring the effectiveness of the program in
         terms of level of patient care delivered.
         According to the application, this proposal will relate to and enhance  each  of
         the-Region's strategy components as determined by the Regional  Advisory  Group.
         Additionally,the region reports that the innovative character  of  this  program
         has engendered so much interest that the region has received requests from
         three additional hospitals and medical staffs to be included in the program.
         The continuing education activity is the product  of three  part-time  physician
         coordinators who have been assigned by the region to the three  areas  for  some
         time. Their mission has been to develop a program based  on  local  need  rather
         than on subjects a distant person believed local physician would want  or  need.
         The Regiongs full-time Planning Director will be available for overall project
         coordination.
         Evaluation will consist of pre and post-clinical performance using the analysis
         of hospital charts for base-line data. $34,200 of the  total  three-year  budget
         request of $48,450 is for consultant services. These fund* are  to  be  used  to
         purchase the necessary expertise, either from the medical schools  or  the  coa-
         munity, to conduct the continuing education activity in the given areas.  If
         this experiment proves successful, continued local support is anticipated
         through medical societies, hospitals or voluntary health agencies.
         Second Year-                                                  Third Year
         $15,850                                                       $150850







                                                  -6-                   RH  00056  5/71
         BI-STATE REGIONAL MEDICAL PROGRAM



                                            ADDGNDUM



           Gereral Con@erris of Staff:


              1.  The "turf"  problem  between the Bi-State and   the Illinois Regional
                  Medical Programs.

              2.  At what level in the local review process vetoes may be im      posed
                  appc@aled?


              3.  Staff would be interested in kiio@, yitig the type of  activities  and
                  the number of proposals which have been disapproved in the local-
                  review process.

              4.  Evaluation methodology.

              5.  Staff was  not convinced that the data collection system proposal
                  would actually strengthen the planning efforts of the Region.

              6.  Assignment of a field Coordinator to the Springfield, Illin     ois
                  area in view of jurisdictional and geographic problems which are
                  about to surface.

              7.  Contributions being made   toward the goals  and  KIP  objectives  by
                  the six categorically assigned Associate Directors'to the two
                  medical schools.

              8.  Lack of impact operational projects have on the improvement of
                  the Delivery of Health Care.

              9.  How some of the minimal requests for carryover ($200 - $350)
                  were processed through the local review system.

              10. The Region be  given  consultation  concerning  Coundil's  July  1970
                  decision as relates to the s  tipeiids, travel, etc., for short-term
                  traineeships.















                                                                         GRB/3/11/71







                                                                          (A Privileged Communicat4-on)

                                 S@- it!' OF @UIVTEt4 P-@'D CONCLUSION O@


                                    APRIL J.971 PLPVIEW C(Yt@'IIITTEE


                                 BI-STATE !?.EGIONAL MEDICAT- PROGRAM

                                        P,M 00056          5/71

                      FOR ""ONSIDERATION BY  MAY 1971- ADVISOIZY COUNCIL


                RECOMMENDATION:  The Review Comni@i-ttee recommends that this supplemental.
                                    application which requests support for two- new projects
                                    be partially supported as follows:


                                                                                        RECOINZIENDED
                YEAR                                    P@r@2@EST                         FUNDING

                lst                                    $52,1-40                          $16,750
                2nd                                      36,838                           15,850
                3rd                                      30,850                           15,850

                      TOTAL                            $119,828                          $48,450


                CRITIQUE:  The   Committee   noted   that   the Bi-State  RMP  will   submit   its
                            anniversary review application in time for review during
                the July/August 1971 review cycle.  Also, the reviewers were satisfied
                that tne  Region  will  relate,  in  this  future  application,  to  til-@.e  con-
                cerns of staff which were raised during staff's review of the Region's
                second year continuation request.

                Since   this   optional   application    included only two projects, the
                Committee  did  not  have   an   opportunity   to study   the   potential   impact-
                on  the  entire   program.   It   was   concluded ,-hat the adding of Project #16-
                To Deve@o a Model. for Te-@ti-i@i,, I  ,s4-c-'Lan Continu@,@ti(L tion would
                add  strength  and  balance  to  '@-he  Re@ion.  @lenibers  of  the  Committee
                believed  that  the  proposed  activities   were   innovative;   that   the   pro-
                gram was presented in a proper cooperative setting; that the fiscal
                request was reasonable; and t[iat further plans forthe program include
                continued support from local sources.  Conversely, the Committee
                viewed  project  #15  -  A  Public  Edticatj@-on  ProRram  on  Harmful  Effect
                of @igare t@@  ni
                                        -,s  a  program  which  contained  nothing   new,   I.acks
                innovation  and  riote@i  that  many   similar   antismoking   programs   have
                alread37  been  supported  across  the  country.   It   was   concluded   that
                this project would not be a priority for use of @,@rP funds.




                                                                                    GRB/RMP    S
                                                                                    4/21@ / -11








                             REGIONAL MEDICAL PROGRAMS SERVICE


                            CALIFORNIA Regional Medical Program
                             RM 00019 5/71  (Special Action)

                     FOR CONSIDERATION BY APRIL 1971 REVIEW COMMITTEE



         STAFF INFORMATION
         This project was one submitted by the California Committee for Regional
         Medical Program for the November/December 1969 review cycle.  The Lockheed
         Corporation, by means of a contract with Area 1, collaborated with personnel
         at Mt. Zion Hospital in the development of an electrocardiographic sur-
         veillance system which monitors silently a large number of patients
         simultaneously and continuously.  The monitoring is silent until a deviation
         occurs, and there are no practical limitations to the number of patients
         or their locations.
         A site visit team,, which included an expert in biomedical applications of
         such techniques, visited the Mt. Zion Hospital in October 1969, to observe
         the system in action.  The team found the project interesting from a number
         of standpoints, but had some concerns, largely technical, which were
         later relayed to the region.  The proposal was also reviewed by the ad hoc
         Cardiovascular Panel and the following concerns reflect the opinion of
         all reviewers, including the National Advisory Council:
         1. the educational aspects of the overall program were not clearly described;
         2. evaluation methods were thought to be vague, with no record system to
            describe events monitored;
         3. the validity of alarm signals was not clear;
         4. the contribution of Lockheed Corporation to further development and
            de-bugging was not specified; and
         5. the system had not received sufficient time for more extensive testing
            in a clinical setting.
         The team felt that approximately a year would be required to de-bug the
         system completely and allow the Mt. Zion personnel to test it before extending
         it to more remote hospitals in Area I.
         The Lockheed Corporation has offered to assume costs for instrumentation and
         engineering for three years at a total cost of $495,300.' CCRMP feels it is
         important for this program to continue to carry the label of RMP in order to
         assure that certain aspects concerned with patient care services, regiona-
         lization and professional education, etc., are retained in the program in
         a meaningful way.  The amount to be allocated from CCRMP funds is $35,446 (d.c.)
         for personnel.  A cost breakdown prepared by Lockheed is a part of the
         revised application, and provides a written understanding of terms of the
         arrangement.







         Specidl Action - page 2

         The revised proposal was submitted to Doctor J. Franc is Dammann, Professor
         of Pediatrics and Biomedical Engineering, who served as consultant for
         this project on the site,team of October 1969.. -Dr.@ Dammann very graciously
         agreed to review the revised  rotocol for the Mt. Zion program and his
                                      p
         report of March 2, 1971 is attached.











































                                                                  RMPS/GRB 3/17/71





                         UNIVERSITY OF VIRGINIA SCHOOI OF rViEDlClr,4E
                               UNIVERSITY OF VIRGINIA HO--PITAL
                                 CHARLOTI'ESVILLE. VIRGINIA. 22901


        TMENT OF PEDIATRICS                                        March 2, 1971
   Division of Pediatric Cardiology
          Research - Box 218







              Jessie F. Salazar
              Public Health Advisor
              Grants Review Branch
              Health Services and Mental Health
                  Administration
              Rockville, Maryland  20852

              Dear Mrs. Salazar:
                   Per your request, I have reviewed the updated and revised project
              for patient monitoring at Mt. Zion Hospital in San Francisco. I believe
              that the applicants have satisfied all of the site visitors major objections
              to the program as it originally was set forth.  Therefore, I think it very
              appropriate for the Regional Medical Program to support it as it now
              stands.
                   Three major changes in the program have been made which answer
              most of the site visitors concerns.  First, I deem it very appropriate
              indeed that Lockheed has agreed to pick up the expenses of building the
              system for trial at Mt. Zion Hospital.  It seems to me to put the
              association of medicine, government and industry on a much more solid
              base, whereas government picking up the expense of the system did not
              appear to be justifiable.  Secondly, the decision to restrict the systems
              trial in the field to Mt. Zion Hospital until after a total evaluation has been
              made also is wise.  The system will get a solid evaluation before additional
              sums of money are spent to develop additional systems,  This is a logical
              way to proceed.  Finally, the applicants have recognized the need for a
              sound objective assessment of the value of the system in the patients at
              Mt. Zion Hospital.  The results of that evaluation ought to be meaningful
              indeed, and ought to gi;e a firm basis for decisions concerning construction










         of additional units, modifications to be made in the units'and the
         benefits that might be expected from expansion to other hospitals.
         This plan for evaluation of the system as it was designed, takes
         care of objections that I voiced concerning the system. A complete
         study of all signals and alarms with emphasis on false alarms, failure
         to alarm and true alarms will establish whe ther the system can carry
         out what it was designed to do or whether changes in design approach
         are indicated. Since the system is unique and my concerns, were
         primarily theoretical, it certainly deserves a comprehensive trial,
         provided of course a complete evaluation is carried out. I think it very
         likely that such an evaluation will be carried out and therefore, I think
         it very appropriate that the program,continue as outlined-

            To recapitulate, I believe that the changes that have been made in this
         program since our site visit meet our objections and that therefore the
         program should be supported. as it now stands. Considering the manpower
         shortage and the potential value to community hospitals, if the trial at
         Mt. Zion proves strongly positive, I think this program should be supported
         at a high priority.

            I would very much appreciate personally if it is possible hearing ho%v
         this program evolves, whether it is supported and what the results of the
         evaluation are.


            Thanks for letting me review this application. If there are further
         remarks that you need from me, please let me know.



                                             Sincerely y



                                             J. @rancis Dammann, i'O. D
                                             Professor of Pediatrics and
                                             @omedical  Engineering

         JF'D/vms




                                                           (A Privileged Communication).



                              SUMIA,RY OF REVIEtq AND CONOULUSION OF
                                  APRIL 1971 REVIE!@7 COMMITTEE


                             CALIFORNIA REGIONAL MEDICAL PROGRAM
                                RM 00019 5/71 SPECIAL ACTION #1


                        FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL



           Project i@41 (Revision 2) - Area I - Patient Monitoring

           Recommendation:- Committee recommended approval of the proposal with
                            no additional funds.
                 Year                          steel            Recommended

                                          $35,446                APT)rOvq i
                  02                       36,178                Approval
                  Total                   $71,624 (Dirc..,ct: Costs)


              k Bound:  The Committee briefly reviewed the history of this proposal
                   --   which began in 1969.  It was reviewed on site in October 1969
           and was recommended for return for revision because of several technical
           concerns   Council concurred.  The proposal was revised and resubmitted
           to the July 1970 review cycle at which time Council concurred with the
           recommendations at the ad hoc Cardiovascular Study Panel that the pro-
           posal required further revision.  At that time the application was still
           believed to be unappr6vabl.e on technical grounds.

             ,iti ue:  The revised proposal appeared to satisfy the specific concerns
                      which had been relayed to the Region,  Some,.discussion revolved
           on the point of the value of the evaluation effort RMPS is asked to
           -support.  The original proposal included a budget approximating $260,000.
           The revised version requests only $35,4.46 mainly for personnel since
           Lockheed has agreed to assume the costs for instrumentation.  The'
           reviewers felt that this joint industry - medical effort provides a
           solid,.practical basis for development 'and@@.thcit CCE-74P's proposal to
           evaluate the clinical usefulness of the system is an important aspect
           of the undertaking.  Further, the reviewers &greed that the region's
           endorsement (RLIP label) for this system,is also important.

           Drs. Mitchell Spellman, Gerald Besson,, John Mitchell and Donald. Brayton
           were not present during the discussion of this Li-
                                                      L)    ,)plication.

                                                    RMPS/GltB/4/26/71








                                REGIOINAL IEDICAL PRO"7P-AMS SERVICE

                               CA',r,IFORNIA Regional Medica' Pro-ram
                               RM 0001.01 5/71  (Special. auction #2)

                        FOR CONSIDERATION BY APRIL 1971 REVIEW CO,@LIITTEE


                California RM 00019 "Cooperative Planning Effort of Regional
                Medical Programs and Model Cities for Training in the Allied
                Health Professions"


                This is a new program to be based in Core Staff activities in
                Area 1, San Francisco.  It is an outgrowth of Regional Medical
                Program participation in health planning for the Richmond Model
                Cities Program.  There are six Model Cities in Area I, and this
                request is made for support to explore solutions to the health
                service problems, particularly in the field of training of allied
                beal.th professionals.

                This is an 18-month proposal requesting $73,349 d-'@rect costs for
                the first year,and $39,333 direct costs for the remaining six
                months.

































                                                                       GRB/4/19/71






                                  SUMMARY OF REVIEW Xiilj '@'OiNCLUSION <)F-
                                      APRIL 1971 REVIEW COMMITTEE


                                  CALIFORNIA RECIONAI, MEDICAL PROGRAM
                                    RM 00019 5/71 SPECIAL ACTION #2


                           FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL


             "Cooperative Planning  Effort  of  Regional  Medical  Programs  and  Model
             Cities for Training in the Allied Health Professions" - Area I

             Recommendation:  Committee  recommended  that  the  request  be   returned
                               for revision with advice as enumerated below.

                  Year                       Request                 Recommended

                    01                    $   73,349                     -0-
                    02                        39,333                     -0-
                   Total                    $112,682 Direct Costs        -0-


             Critioue:  The  reviewers  agreed  that the proposal was a  well   written
                       planning document, but that therein lay an overriding
             negative factor.  The proposal represents a          ni-Li effort while  ,-he
             Model Cities endorsement  fosters  a@  action  plan.  There  is  no  action
             target  t0 be r6acbed in the 18-month plan.

             Committee believes the proposed program     area of involvement is of high
             priority, and if the real  "product"  is  the  training  of  allied  health
             professionals, then the methodology should be redirected--not to
             employ "Planners" but to develop  steps  of  action  to  reach  the  people
             in the target districts.

             The Committee suggests that  the  Region  arrange  its  own  "site  visit"
             method, drawing on regional consultative resourc6s such as Dr. Stanley S.
             Skillikorn in Area  III  (for  his  planning  for  health  delivery  improve-
             ments in  th6.Cardner  district  of  San.Jose),  and  Dr4  Mitchell  Spellman
             in Area IX  (for  functional  experience  gained  by  the  Drew  Postgraduate
             Medical School planning).  Hopefully, the-bext step can be a more
             affirmative action plan.

             There was consensus that the proposal would benefit by a "phased"
             approach.  During phase one, staff would be hired, utilizing consultants,
             and initial  cooperative  arrangements  should  be  firmed  up.  Phase  two
             would involve careful review of the Task Force (site visit) recommenda-
             tions by CCRMP sta ff and RAG.  Phase three would present the recommendations
             of the Task Force to the Model Cities Health Council and other appropriate
             agencies for action and implementation.

             Staff.Note: February  1971.  Council  approved  the  use  of  Developmental
                           Component funds  by  the  California  RMP.  The  Region  will
             submit a triennial application May  1,  which  will  be  reviewed  by  the
             July Committee  and  August  Council.--

             Drs. Mitchell Spellman, Gerald Besson, Joll-@i             end Donald Brayton
             were not present during the discussion of -@lt@'s a-t-)pl@Lcation.









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


            IOWA REGIONAL MEDICAL PROGRAM                        @l 27-03 5/71
            University of Iowa                                   April 1971 Review Committee
            308 Melrose Avenue
            Iowa City, Iowa

            PROGRAM COORDINATOR:  Harry M. Weinberg, M.D.

            This application requests supplemental funds to support five new
            operational projects.  The Region's Triennial application is due in
            August and will be reviewed by the October Committee and November
            Council.
                                               Requested (Direct Costs Only)
            Project # and Title        01 Year    02 Year    03 Year       Total

            #17 -Laboratory  Improve-   $45,182   $   35,337 $  25,141     $105,660
             ment Program
            #18-Minowa Continuing        45,200     45,192      46,275     136,667
             Education
            4kl9-Renal  Failure  Manage- 80,317     83,508      87,839     251,664
             ment Training
            #20-Organ Procurement        48,920     35,272      36,719     120,911
             a Preservation
            #21-Multimedia Nursing       108,737    35,500      22,500     166,737
             Education


                  Totals               $328,356     $234,809   $218,474    $781,639

            The last staff review in   January 1971 noted  that the region  has  made
            considerable progress in   the following areas: The  Core  staff,  for  the
            first time since the inception of this Region is now fully staffed;
            the Regional Advisory Group which has been increased from 46 primary and
            alternate members to 76 primary and alternate members appears to be a
            truly regional cohesive group which  shows  great  strength  and  ability
            in the Region's decision-making process  and  in  providing  guidance  to
            the Region: and in the development of cooperative arrangements with
            Community hospitals, and the involvement  of  the  various  disciplines  of
            the allied health professions, practicing physicians and the University
            of Iowa Clinical faculty in the planning and decisioh-making process of
            the IRMP. The operational activities  are  primarily  in  the  heart  and
            stroke areas.

            Staff recommended  approval  of  the request for continued funding for the
            03 year at the commited level of $651,417.  However,  due  to  1  71  fisca
            contraints, the region will be funded in a reduced amount of $596,047 (d.c.o.)




              Iowa Regional Medical Program             - 2            RM 27-03

                                              FUNDING HISTORY


                                               PLANNING STAGE


              Grant Year                     Period                        Funded (d.c.o.1

                 01                 12/l/66  -  1/31/68  (14  months)           $214,000

                 02                           11/30/68  (10   months)            213,000

                                            OPERATIONAL STAGE

                 01                   7/t/68  1/31/70                           $455,000

                 02                   2/l/70- 1/31/71                             736,67.3

                 03 (Current Year)    2/l/71 -i2/31/72 (11   months)             596,047

              Following is a listing  of  the  03  year funding status of Core and
              the Operational  Projects  in  Iowa  RMP:

              Project No.                   Title                   Amount     Supported

                                                                Thru 12/31/71 (d.6.o.)
              #1                      Core                                $290,070

              #2 & #3                 Ventral Stroke Educa-
                                      tion  and  Stroke   Management       134,930

              #4                      Training  Program  in   Cardio-        3,985
                                      Pulmonary Resuscitation

              #5                      Coronary  Care  -   Supervision
                                      Training  for  Physician  &  Nurses   65,712

              #11                     Pediatric Cardiology Training        :51,400
                                      Program

              #12                     Cancer   Educational   Program         2,355

              #13                     Mobile  Intensive  Care   Unit        37,460


              #14                     Cardiac Auscultation Training
                                      for    Physicians                     10,135

              Total                                                       $596,047

                 Members of staff have  learned  that  the  amounts  shown  reflect  the
                 revised  budgets  for  these  components.  The  reduced  amounts   were
                 approved by the Iowa Regional Advisory Group on February 28, 1971.
                 It was also learned that project  #4  and  #12  will  terminate  as  of
                 April 1, 1971.  It was further indicated that the Iowa Heart
                 Association would assume full funding of project #4 at that time.





            Iowa Regional Medical Program             - 3 -            RM  27-03   5/71



            SUMMARY OF NEW OPERATIONAL PROPOSALS


            Project #17 - Laboratory Improvement Program

                                01                   02               03
            Requesting   7/l/71-6/30/72      7/l/72-6/30/73      7/l/73-6/30/74  All Years

            Direct Costs     $45,182             $35,337            $25,141       $105,660

            The State Hygienic Laboratory through  the  Iowa  RMP  requests  three-year
            funds for a program which has been funded through the Office of Compre-
            honsive Health Planning since February 1969.  The program is designed
            to increase the general level of competency of clinical laboratories
            in the Iowa Region.

            The ultimate goal is to improve health care delivery at a local level
            by a comprehensive continuing education program for clinical laboratory
            personnel within the districts and  sub-districts  of  the  Iowa  Region
            and to have available to all  Iowans,  adequate,  accurate  and  totally
            capable clinical laboratory practices regardless of the size on geographic
            location of their local facility.

            The specific aims of the proposal are:

                    (1) To determine the  quality  of  performance  of  laboratories
            in the Iowa Region by ,tilization  of  national  and  local  proficiency
            testing programs.

                    (2) To improve the quality  of  laboratory  services  through  a
            comprehensive continuing education program   with the  cooperation  of  the
            Iowa Association of Pathologists.

                    (3) To assist  participating  facilities  to  provide  standardized
            equivalent laboratory services to all disciplines.

                    (4) To provide consultation  services  to  laboratories  in  the
            Iowa Region.

            In addition to the  State  Hygienic  Laboratory,  the  Iowa  Association
            of Pathologists, the University College  of  Medicine,  the  Iowa  State
            Health Department and  participating  Community  hospitalsare  involved  in
            this activity.

            Project #18 - Areawide Continuing Education for Health Care
                          Personnel in the Minowa Health Planning Area


                               01                  02              03
            Requesting   7/l/71-6/30/72     7/l/72-6/30/73    7/l/73-6/30/74  All Years

            Direct Costs      $45,200           $45,192          $46,275       $136,667




           Iowa Regional Medical Program         4

           This proposal is an outgrowth of interest among six Northeast Iowa
           counties to coordinate efforts to supply a continuing medical and
           health science educational program for health care personnel of their
           combined areas.  The project is designed to demonstrate the feasibility
           of such an undertaking in a rural environment, where the accessibility
           and adequacy of continuing medical education currently fall far short.
           of satisfying the needs of health care personnel.
           The project proposes to:  (1) identify and improve continuing edtica-
           tion programs for physicians and allied health care personnel; (2)-
           identify unmet and fill needs for continuing education; and (3)' com-
           bine or link together hospital and other related'agency or community
           programs.  The continuing education programs planned under this pro-
           posal will be primarily for the counties  of  Howard,  Winneshiek,  Allamakee,
           Chickasaw,Clayton and Fayette;  however, perso=el from contiguous
           counties in Iowa, Wisconsin or Minnesota will, :Lf  interested,  be  permitted
           to participate in any of the activities.
           The project will be based at the Area.l.,Vocational-Technical School
           at Calmr in Winneshiek County.  Other agencies involved in the devel-
                                                        clude the-Mi'owa Area Health
           opment and implementation of the program in            ,  n
           Planning Council, The University of Iowa College of Madigtne, the Mayo
           Clinic, the Adolf Gundersen Medical Foundatim ila Wiscoiii-in and four
           hospitals in the six-county area.  The Minowa AreaHealth,3?lan'ning
           Council will provide overall direction of the project through a
           12-member steering committee who will act in an advisory capacity in
           surveying the medical community to determine the educational needs,
           setting priorities and developing curricula.  The University of Iowa
           College of Medicine, the Mayo-Cltftic, the Adolf Gundersen Medical
           Foundation will provide teaching  personnel  and  consultative  s.ervices,
           the latter being utilized in establishing priorities and developing
           curricula.  The four hospitals have agreed to place the coordination
           of their in-service programs under the project.  A Project Director
           will be employed.
           Local funding of this project will be accomplis   hed by progression (over
           a three-year period) in the tuition charged to participants involved
           in the program and through charges imposed on the hospitals for
           coordination and provision of in-service training.  It is expected
           that many of the on-going programs can  be  incorporated  with  the  Community
           College structure and financed by tuition charges and school tax funds.
           #19 - Renal Failure ManaRement Training
                               01                0 2               0 3
                stin  _,,--771/ 1-6/30/72   7/ /72-6/30/73    7/l/73-6/30/74    All years
           Direct Costs      IltoO,317         $83,508           $87,839         $251,664



        Iowa Regional Medical Program        - 5 -              RM   27-03   5/71


        This proposal represents part of a cooperative  effort  of  a  number  of
          ncies in Iowa to organize an effective plan for the  care  of  the
         tient with utemia. Involved  in  this  development  are  the  University
          ical Center-including the University  of  Iowa,  University  Hospitals,
        and the VA Hospital and the Regional Medical Program; a number of
        communities of the State; insurance underwriters;  voluntary  health
        agencies; the Legisldture; the State Department of Health; and many
        private citizens.

        The specific aims of the project are:
        1) To provide practicing physicians a course of intensive  study  in
        clinical nephrology. The course will vary from one week  to  six  months.
        A total of twenty (20) physicians are expected annually in the one-
        week course and two physicians for  one  month  or  longer.  Participants
        will be capable of improving the general level of care  of  patients
        with renal disease and hypertension. With  adequate  support  they  would
        be able to manage small dialysis  centers,  stations  for  home  dialysis
        supervision and instruction, and  units  where  cadaveric  kidneys  might
        be retrieved.
        2) To train nurses to staff areawide nephrology units (satellite centers).
        Two types of educational programs  will  be  offered.  The  first,  which
        will be four weeks in length, will be a basic  indepth  educational  pro-
        gram to prepare nurses to care for patients  receiving  hemodialysis
           to supervise other nursing personnel.
         ,rty (30) nurses will be trained in  the  preparatory  hemodialysis  pro-
        gram in the first year; twenty-four (24) in the second year and eighteen
        (18) in the third. Ten (10) nurses will receive  training  in  the  devel-
        opment and administration of a hemodialysis training  program  during  the
        first year and twenty (20) will be trained in the program  to  deal  with
        home dialysis and the care of the patient with  renal  hotwtransplant.  A
        second educational program -consisting of  workshops  will  provide  con-
        tinued development of nurses in the  community  involved  in  caring  for
        patients on dialysis or those who have been transplanted.
        3) To establish workshops for  technicians,  social  workers,  dietitians
        and public health nurses to orient them  to  special  problems  presented
        by patients with renal disease. Annual workshops  will  be  held  at  the
        University of Iowa Medical Center for this group and at  least  one  visit
        will be made annually to each of the  satellite  centers  by  members  of
        this group to observe problems associated with the sate     te  cen  ers,
        suggest solutions and promote  communications  within  the  system.  Some
        of the programs will be interrelated with those of physicians and nurses,
        but special problems in each group will be dealt with separately.
        The applicant is requesting a total of $13,389 for stipends  to  be  paid
        to those physicians attending the program  for  intermediate  periods  of
        from one to six months. The stipends will be paid  on  a  monthly  basis.




          .1-owa Regional Medical Yrogram


          #20 - A Program of Human Organ Procurement and Preservation for use
               in Clinical Transplantation


                           01                 02
                                                               03
          Requesting   7/l/71-6/30/72   7/l/72-6/30/73   7/l/71-6/30/74      All years
                          $48,920          $35,272          $36,719         $120,911
          The overall goal of this proposal is to better utilize existing sources
          ,of organ donors in order to make renal dialysis and transplantation
          available to more uremic patients in the Iowa Region.
          Sponsored by the University of Iowa-Veterans  Administration  Hospital
          Renal Program, the major objectives of this proposal are:
          1) to train organ preservation technician by two months on-the-job
          training;
          2) to develop for clinical use an improved system of organ preservation
          by continuous cold perfusion;
          3) to organize within community hospitals (five initially) cadaver
          organ recovery teams of physicians and nurses, thereby maximizing organ
          recovery potential, this will be coordinated with Project #19;
          4) to,extend cooperation to other regions, continentwide, in order to
          exchange and evaluate a greater number of well-matched, viable organs..
          The IRMP will also assist the Kidney Foundation in launching a campaign
          to stimulate public understanding of the need for organ donors.
          The evaluation activities will be in collaboration with those described
          in the preceding proposal "A Program to Train Physicians and Nurses
                                      if                -
          in Renal Failure Management.  The inte relationship of these two pro-
          'Posals and their co ined impact on renal disease in the  Iowa  Region
          is tied to an increased capacity to perform transplants in Iowa.
          The applicant has requested operational funds for a total of three
          years. However, as the program develops in  clinical  service,  income
          will be generated and will be applied to the costs of continued opera-
          tion of the program.  The extent to which the proposal will be able
          to support itself will depend on the number of organs recovered and
          transplanted each year.  The applicant states that a bill has been
          introduced in the Iowa General Assembly that proposed a fund to assist
          Iowa residents in the payment of medical bills arising from human organ
          transplants and if approved, will enable this activity to become self-
          supporting.




             Iowa Regional Medical Program        7 -


             #21 - Multi-media Nursing Education

                               oi               02               03
             RettgestLI  711/71-6/30/72  7/l/72-6/30/73  7/l/73-6/30/74       All Years
             Direct Costs  $108,737           $35,500          $22,500        $166,737
             The Iowa Hospital, in cooperation with   the Department of Nursing,
             Marycreat College, Davenport, the Department of Nursing, the Mercy
             Hospital, Iowa City and the Audiovisual Center of the University
             of Iowa proposes to upgrade nursing care  in  the  Iowa  Region  by
             utilizing a self-instructional multi-media program of continuing
             nursing education.  The proposal addresses itself to health care
             facilities providing nursing care for patients with cancer, heart
             disease, and stroke during  all  phases  of  their  illness.  These
             include general hospitals,  extended  care  and  convalescent  care
             facilities, nursing homes and outpatient clinic.  The program has
             as its target population, the Registered Nurse.
             The specific aims of the project Are to:  1) develop a programed
             course manual and multi@dia  materials  to  be  used  in  a  self-
             instructional continuing nursing education program; 2) demonstration
             in five community hospitals  thp-  feasibility  c  the  programmed,
             self-instructional  multl-mdia  par-kage'for  continuing   nursing
             education;, 3) evaluate the program continually in order that
             the,program format and-coutent may be adopted to changing needs
             And demands; 4) make available  to  health  care  institutions  and
             and 4@ies itt the Iowa Region a self-instructiorlal multi-media
             prograt% of Vtttltxuing nursipg -.education and; 5) evaluate the im-
             pact of the liroject vitirei-ng attitude and behavior in the  Iowa
             Region.  #omo of ttle expected advantages of this approach are
             that it willoprmit each hospital or health facility, regardless
             of size or location to update the  knowledge  of  its  nurse  prac-
             titioters 4i@4out sending them  away  and  losing  their  services
             for va;:ying@@eriods of time. It  reduces  the  cost  of  carrying
             on an effective continuing  education  program,  because  it  elim-
             inates the use of live teachers to keep repeating a program.
             Additionally, it will allow an inservice educator to use her time
             more productively and it will encourage recruitment of inactive
             nurses back into nursing by offering them an opportunity to up-
             date their skills at their own pace.
             The applicant states that the proposal will become self-supporting
             after RMP funding has been terminated.




                                                                RMPS/GRB/3/16/71








                                                                     (A Privileged Communication)

                                      SUMMARY OF REVIEW AND CONCLUSION OF
                                         APRIL 1971 REVIEW COMMITTEE


                                         IOWA REGIONAL MEDICAL PROGRAM
                                               RM 00027-03 5/71


                                  FOR  CONSIDERATION  BY  MAY  1971  ADVISORY   COUNCIL


                'RECOW@ENDATION:.   The Review Committee recommends that no additional
                                    funds be provided for this,application.  The Ad
                Hoc Renal Panel,    on the other band, believed one of the two Renal
                proposals, which    were a part of the application, was     funda le at
                a reduced level.


                                                 DIRECT COSTS ONLY


                  YEAR                                   REQUEST                RECOMMENDED

                lst year                                $328,356                   -  0
                2-nd year                                234,809                   -  0

                3rd year                                 218,474

                      TOTAL                             $781,639                      0


                     I UE:    The reviewers noted that the     Iowa  Regional   Medical   Program
                              will  submit  its  Triennial  application   for   October/November
                1971 Review   Corri-,i--.ttee and Council. The Review Committee  was  in  agree-
                ment that the Iowa P@IP has a dynamic program and the five proposed
                activities, although lacking innovation, are essentially excellent
                projects.  However,  both  the  primary  and  secondary  reviewers   were   con-
                cerned that the proposals are not congruent w@th the emerging goals
                and 6b .ectives of Regional Medical Program Services, as described
                       i
                in the Ptesident's Health and Budget Messages, and that providing funds
                to support these activities would not be a priority use of RMP  uil s.
                Some of the Committee felt that disapproval of the projects was anti-
                thetic to the concept of decentralization and 1(.cal goal.-setti.ng.

                In teaching a recommendation, eleven (li-) of the reviewers were in
                agreement, -while three (3) members opposed and one (1) member abstained.








               Iowa RMP                             2                         RM 27@03 5/71'



               Renal Projects

               During its review of this application the Committee did not have the
               benefit of the recommendations of the Ad.Hoc Panel on  Renal  Disease
               which met concurrently with the National Review Committee-.

               'fhe Ad,Hoc Panel on Renal Disease believed that Project #20 A Program
               of Human Organ Procurement and Preservation for use in Clinical Ttdns-
               plantation wastechnically sound and worthy of support  at  a  reduced
               total -jamount of $43,500 for the lst year. Specifically, the  Panel
               believed reductions were warranted in the categories  of  personnel,
               consultant services, supplies and equipment. Regarding  the  2nd  and
               3rd years of support, the Panel believed that actual  funding  would
               have to be determined by the progress made during the lst year of
               the project.

               #19,- A Proposal to Train Physicians and Nurses in Renal Failure  @na e
               ment.  The Panel did not believe that this project should be supported.
               The proposal appears to be a poorly conceived effort to provide support
               for the training of renal fellows which is not appropriate under RMPS
               policy.  Further, thd Pan-el suggested that the Region may wish to
               direct its efforts in the area of the development of  home  dialysis
               training programs*

               Miss Kerr was not present during the Committee discussion  or  action
               on@thig application.


















                                                              R@IPS/GRB 4/23/71







                                               KANSAS


                                               SUMMARY


                                         Table of Contents



                                                                              P.
                    Fiscal Information
                    Geography and Demography                                  p.  5
                                                                              p.  5
                    Regional Development                                      p.  8
                    Organizational Structure and Processes                    P.  8
                    Regional Objectives                                       P.  9
                    Developmental Component                                   P.  10
                    Application
                             Core                                             P.  10
                             Continuation Projects                            p.  12
                             Renewal Projects                                 p.  12
                                                                              p.  14
                             Approved but Unfunded  Projects
                             Supplemental Projects                            p.  16






                                     REGIONAL MEDICAL PROGRAMS SERVICE
                       SUMMARY  OF  ANNIVERSARY  REVIEW  AND   AWARD   GRANT   APPLICATION
                                        (A Privileged Communication)
               KANSAS  REGIONAL  MEDICAL   PROGRAM                  Rm 00002-05,  5/71
               3909 Eaton  Street                                   April 1971 Review Committee
               Kansas City, Kansas  66103
               Program Coordinator:  Robert W. Brown, M.D.
               This region is currently funded at $1,633,600.,(direct costs) for its third
               operational year (which is an,ll-month period) ending June 30, 1971.  It
               gubmiti a triennium application that proposes:

                                I -A Developmental Component
                               11 -The continuation of Core and 2 ongoing activities
                              III -The activation of 4 Council approved but unfunded
                                       ctivities
                               IV -@e renewal of 6 activities
                                V -The implementation of 1 new activity
                               vi -The termination of 2 activities
               The Region requests $2,244,073 for its fifth year of operation, $2,158,176
               for the sixth year, and $2,503,999 for its seventh year.  A breakout chart
               identifying the components for each of the three years follows.
               A site visit it planned for this region, and staff's preliminary review
               of the application has identified several issues for the site visit teamis.
               consideration.  These are also covered briefly in this summary.

                                                 FUNDING.HISTORY


                                                    Planning
               Grant Year                    Period                        Funded    d. c. 0.
                    01                  7/l/66   -   6/30/67                   $1.80,520
                    02                  7/l/67   -   5/31/68                       205,891

                                              Operation       o ram
               Grant Year                     Period                        Funded  (d.c.o.)
                    01                  6/l/67   - 5/31  /68-                $     592,248
                    02                  6/l/68   -   5131/69                   1.1644,819
                    03                  6/l/69   -   7/31/70                   2,096,926  (14 mos.)
                    04                  8/l/70   -   6130/71                   1,633,600  (11 mos.)
                    05                  Future   Commitment                    1,353,159
                    06                  Future   Commitment                    liO25,702











                                                                                                                                          I 000@2     5  /71
                                                                                                                             CYCLZ
                                                                                                                                        (Tr4@enniu-







                                                                                                                6'; .1
                         DEVFLOP@TAL           'T                                                                      o@
                                    COLMPONE'@\


                                                                 410
                                                         1  171
               !C
                       Eilucational  Proqra-ls                                                                                                1      @6.11
                                                                          !$I    @9,574
                   #IR- Great Benci                                -
                                                                                                                                                          47      175,n
                                                            136,441
               @#4     Cardiovascular N
                                                                                                                                                         O'        50,056
                                                                                                                                        I(?,526
                                                                              lq,526
                           CE   for Car,lioc  Cnre
                                                                                           1                                                 74        9,864       41,938
                                                                              32,074
                  OR       Nurse  RetrAining
                                  r                 0.                                                                                                   3         50,288
                                                                                                                                         3?,345      11,94
                           Nurse   Training                                         345
                                                                                                                                            683                    68,961
                                                                                                                                          1,683        7,278
                   #23R    medical Library Svst.,                             6   6   3
                                                                                                                                         12,000        1,599       13,599
                                                                              12,000                                                                          I
                           institute for Dietitians                                                                             ----                          i
                                                                                                                                          6,415     -0-                 6,415
                           Med, Record Clerks CZ                6,415
                                                                                             $133,673                                   133,678       23,933       157.611
                   -740
                           Comprehen. Neplro
                                                                                                82,803                                   82,803       19.671       102.474
                   is4l    Cancer Info. Center
                                                                                                                                         64.262        8,692            2,954
                                                                                                 64,262-
                   :#42    cE Cancer Care
                                                                                                                                                                           98
                                                                                                                                        125.212       12,786       137,9
                                                                                               125,212                                       --          ---
                   @,44    Nurse Clinician
                                                                                                                                                       -0-          37.290@
                                                                                                                  $3.7,290               37,290
                    #45    Model Cities





                                                          $1,314,266        $323,202         .$405,955         $200,650          $2,244,073       $506,504      $2,750,577














                                                                                                          Ri;Gic@@  KAN'SAS
                                                                                                                   R,-i ('LIUUZ   @171
                                                                                      (:6        PZ'P@ICD           T ieni..)



                             c
                                                                                          -AG

                                                                                            $201.134                                       2
                                                                                                          $      201.134     -0-           21    134
                  @@L 0
                                                                                                                                  ool- 1.744,28

                                                                                                           i    10,44-6       35,514:      145.960
                                                               $110,446


                  #4

                  #-8R

                    @9R

                  #21R
                                                                                                                68,846         5.,481      74,327
                                                                 68.846
                  #23R


                  #32R


                  #38
                                                                                                                 108,081     .26,078       134,159
                  #40                                                         $108,081
                                                                                88,358                          88,158   1   21,435        109,793
                  #41
                                                                                70,957                          70,957       13,238        84,195
                  -142                                                                                                        -    -
                                                                                                                                           136.116
                                                                                                                 122,183     13,933
                                                                               122,183
                  A44
                                                                                                                                           37,290
                                                                                               37,290           37,290
                  -f 45





                                                                                                                                         @$2,667,255
                                              $1,350,881        $179i292      $389,579       $238,424         $2,158,176    $50@,,079




                                                                                                                                                                                2q



                                                                                                                                                                                fA
                                                                                                  07                                                                5171
                                                                                                                                                      RM 00002




                                                                                                                                                    599                   .122
                     DE@IEL.                                                         $234,628                         -0-                                    i
                                                                                                                                                  ii4.142.374        5.336,860
                                                                                                      1,620,083 $ 475,
                     CORE        1$1,6200083
                                                                                                                                                                    47 17@
                                                                                                                       37..338     154  3@       367       35
                                                                                                           1171,015,
                     i'IR                                1015
                                                                                                                                                      136,441       175.088
                     #4
                                                                                                                                            ii         39.526       50,056
                     i-8R        i
                                                                                                                                                   3  2     4       41,938
                     #9R                                                                                                                              LO74
                                                                                                                                                                    50,288
                                                                                                                                                    '38    145
                     -42IR
                                                                                                                                     87.226@          211.125
                                                       80,596                                             80                 30                                     230,514
                     #23R
                                                                                                                                                                    13,599
                                                                                                                                                       12.000
                     #32R                                                                                                                                        ----
                                                                                                           ---                                        6,@5               6,415
                     #38
                                                                                                              4,7461                 43,161@         35         @34IL3@'
                     #40                                             114,746                                             28,415:                        !L 5@
                                                                                                                                                                            35
                                                                     101,314                         1   101    3141     23,354     124.668@          272,475            6-935
                     441
                     #@2                                                                                      2,1721     13,695       85,867@       2-07,,391       243,01
                                                                                                              6,155i     15,180      14i,335@         373,550       415@449
                     -v444
                                                                                                                       -.0-           37,290@         111,870
                                                                                                                                                                    111,870

                     #45




                                                                                                                                                                '$S,,522.2.98
                                                                                       $271 918      '$2,503,999, $600,467        -.43,104pa@         906,248
                                                                                                                                                $6
                         O',-" A-,               3     $197,-611    $414,357
                                     $1,620;08





                                              -5-                   Rm 00002  5/71
           Kansas RMP


           Geography and Demograph
                                -y
           The Kansas RMP boundary is the Statels.  A population of 2,200,000 is contained
           in the 82,000 square-mile area.  The Region is primarily rural; its two
           largest cities are Kansas City and Wichita. The Kansas  @  shares  boundaries.
           with the Nebraska, Colorado-Wyoming, Oklahoma and Missouri RMP'S.  The
           relationship with the Missouri RMP's activities in Kansas City,  Missouri,
           as well as the medical care flow patterns between the two political units,
           have been difficult to determine and appear to fluctuate from year to year.
           A liaison committee to coordinate the operations of the two RMP's in Kansas
           City was established several years ago, but neither M4P mentions it in their
           present applications.
           The state of Kansas has one medical school - the University of Kansas  and
           34 schools of nursing, including diploma, associate degree and L.P.N. schools.
           There are also 61 schools of allied health.
           Kansas is served by 2,218 pr acticing physicians (there are 2,442 M.D.'s in
           the state), 184 doctors of osteopathy, and 8,323 active nurses (there  are
           11,001 R.N.'s).  There are 173 hospitals in the state; of these, 15 are
           state, military or V.A.


           Regional Development
           RNP planning in Kansas began with a Governor-appointed Commission who
           selected a Regional Advisory Group and named Dr. Mills as Coordinator.
           The planning grant was awarded in July 1966.
           During the first operational year Dr. Charles Lewis was appointed permanent
           Coordinator and a site visit was held.  Both reviewers of the early planning
           application and site visitors commented on the close ties of the RMP with
           the medical school.  The medical school served as both the grantee agency
           and fiscal agent, representatives of the medical school served as RAG Chair-
           man and in charge of important core functions, and early efforts in continuing
           education activities appeared to be a continuation of already existing
           activities of the medical school.
           Conversely, representation on the RAG and involvement in the program of
           community interests, minority groups and other agencies needed-to be  expanded
           and strengthened
           This Region was one of the first to submit an operational program.  The
           Region received funds for projects in April 1967.  One of the first approved
           projects was the Great Bend Educational Program, which was to serve  as  a
           model for developing continuing education programs to attract and keep  health
           care personnel in the rural and small town areas, developing  linkages  to
           provide better care to peripheral elements and increasing the overall
           capacity of providing care. The projecti supported since June  1967,  requests
           an additional three years of support in this application.  Other projects
           approved during the first operation year included:
                     #2 - Reactivating Nurses (Great Bend)
                     #3 - Circuit Course for Active Nurses
                     ff i                      fr@04"4n&






                                                                         RM 00002  5/71
         Kansas  RMP                          -6-


                   #5 - Cancer Detection
                   #61- Physical and occupational Workshops
                   #7 - Cardiovascular Work Evaluation

         All but  Project #4  have  been terminated.
         During the second and third years  a  large  number of continuing.,education
         courses for physicians, nurses  and  allied  health personnel were submitted
         and approved.  The,following is a  listing  of  the activities and their  present
         status:
              #8 - Continuing Education for Cardiac Care           Renewing
              #9 - Metropolitan Kansas City Nurse
                   Retraining   Program                            Renewing
              #10  - Healtb'Dats Bank                              Terminated
              #11  - Self-Instruction Centers                      Termin   ated
              #12  - Training Program for Cancer of the
                     Gastrointestinal Tract                        Withdrawn
              #14  - Perceptual Motor  Dysfunction  Assesment
                     and Treatment                                 Terminated
              #15  - Physical Therapy Workshop                     Terminated
              #16--  Therapeutic Nutrition                         Terminated
              #17  - Cancer Chemotherapy Seminar                   Terminated
              #20  - Continuing Education  Program  for
                     Occupational Therapists                       Terminated
              #21    Cerebrovascular  and  Neurological
                     Nurse Training                                Renewing
              #23    Kansas Medical Library System                 Renewing
              #24    Food Service Personnel  Using  the
                     Dietary Consultant Approach                   Terminated
              #25    Coordinated System for  the  Continuing
                     Education of Medical and Paramedical          Transferred
                     Personnel                                     to Core
              #26  - Cancer-Care  Continuing  Education
                     Program                                       Terminated
              #28  - Seminar on Basic  Medical  Librarianship      Terminated
              #29  - Kansas City Council on  Health  Careers
                     Manpower Recruitment Program                  Approved but  Unfunded
              #32    Institute  for  Dieticians                    Renewing
         While these projects  seemed  to  have developed to solve rather specific
         problems in the allied health and continuing education    areas, the reviewers
         believed there appeared to be an increasing need at the regional level for
         Committees or Task Forces in continuing education and allied health.
         During the second and third operational year,'the KRMP began the build-up
         of the tubregional offices.  Kansas has nine subregions which correspond
         geographically to CHP regions.  Great Bend and Wichita were the-first two
         to be staffed.  Topeka, Colby and Emporia followed in 1969.  Full subregional
         staffing was completed in 1970 with the addition of Garden City, Salina,
         Kansas City and Chanute  (see  attached  map).





             Kansas  RMP                           -7-                      RM 00002  5/71


             A site visit was held January 1969 to learn more about the regionalization
             process, the relationship of projects to the regional plan and to gain more
             information about the decision-making and priority-setting process.  The
             team reported that: 1) significant  progress  had  been  made  in  subregionaliz-
             ation, although there was not general agreement in the Region as to what
             the concept would be; 2) as far as the team could determine, the projects
             fitted into a regional plan; 3) objectives were  very  general  and  not  measur-
             able and it was difficult to determine  that  priorities  had  been  established.
             In February 1969, Dr. Robert Brown, Director  of  the.Great  Bend  project,
             succeeded Dr. Lewis as Coordinator.  With Dr. Lewis' resignation, the
             hypertension earmark project, #19, which  he  directed,  was  discontinued.
             Projects submitted and reviewed since May 1969 include the following:
                   #33 - Nursing in Long Term Illness                  Disapproved
                   #34 - Basic C6ntinuing Education Program in
                         Community Health Nursing                      Returned  for  Revision
                   #35 - Basic Education Program for Medical
                         Clerks in Kansas Hospitals                    Returned  for  Revision
                   #36 - Short Course in Instrumentation for
                         Medical Technologists                         Returned  for  Revision
                   #37 - Care of Patients with Fluid Electroiyte
                         and Renal Problems                            Funded
                   #38 - Revision of Project  it35                     Funded
                   #39 - Demonstration Project to Improve
                         Community Chronic Ilinets Care                Return  for Revision
                   #40 - Comprehensive Nephrology Training
                         Program                                       Deferred
                   #41   Cancer Information Service                    Approved  but  Unfunded
                   #42   Cancer Care Continuing E ucat on
                         Program                                       Approved  but  Unfunded
                   #43   Model Rehabilitation Project                  Funded  by  Rebudgeting
                   #44   Nurse  Clinician  Program                     Approved  but  Unfunded
             The approved  but  unfunded  projects are included in the Triennial   Application
             for  further  funding  consideration.
             In these later applications the Region's program emphasis continued to be
             continuing education and its  program  implementation  to  reflect  a  one-by-ont
             approach to education and training. In  addition,  nursing  input  in  t  e
             development of curriculum or in project evaluation in nurse training project$
             was lacking, as was evid6nce of coordination between various professions
             involved in a single project. At  the  review  of  the  last  continuation.
             application in July 1970, staff raised the following issues:
                   1.  The difficulty in determining the RAG's contribution in policy-
                       making and goal setting;
                   2.  The need for measuring the impact the projects make in the institution
                       and health care patterns, as,well as  for  more  overall  program
                       evaluation;





                I                                                  RM 00002  5/71
       Kansas RMP


            3.  The need for a-regional strategy in allied health and continuing
                education; and
            4.  The need for greater core staff assistance from the central and
                subregional levels to the projects in such areas as formulating
                education design.

       Organizational Structure and Processes
       The Kansas RMP has a 20-member Regional  Advisory Group, which includes five-
       consumer representatives.  The RAG sets  priorities, reviews ongoing operations,
       core staff activities and the activities of the Committees, Boards and
       subregional councils. The  RAG  is  served by the following committees:

            Executive Committee
            Continuing Education Unit Policy Board
            Lead Committee on Cardiovascular Disease and Rehabilitation
            Lead Committee on Cancer
            Renal Dialysis Medical Advisory Committee
            Renal Dialysis Advisory Council
            RAG Committee on the Annual Report
       The specialized committees listed above exist to study problems and offer
       technical advice on policy in tbeir respective area of  ex  ertise.  They  do
                                                                 p
       not participate in the review process.
       In addition to these groups, there are nine Local Advisory Groups, whose
       membership is representative of consumers and most of  the  health  interests
       in each of the subregions.  They serve in an advisory  capacity to the
       Coordinator on matters concerning the health needs, problems and priorities
       and review project applications submitted from their subregion.
       The present review process provides for an assessment by core, the sub-
       regional advisory groups and the RAG. Although review  by  ad  hoc  technical
       groups is shown in the review  process proposed in November 1970, the Coordinator
       has stated that these are not yet operational.  A schematic of the proposed
       review process is attached to the summary.


       REGIONAL OBJECTIVES
       The Kansas RNP has developed the following overall goals for 1971.-
            1.  To strengthen existing cooperative arrangements  to  improve  health
                care and to establish  new  ones.
            2.  To improve health professional performance and thereby patient
                care through effective continuing education.
            3.  To study and modify favorably the factors which influence distribution
                of health professionals and service.





                                                                        Rm 00002  5/71
             Kansas RMP


                 4.   To provide special training opportunities for new or  relatively
                      underdeveloped health professionals.
                 5.   To evaluate components of the health care system and to  support
                      elements which rationally might increase quality, capacity or
                      accessibility.
                 6.   To improve communications, facilities, equipment and  techniques
                      related to the use of these.
                 7.   To improve effects of the program in the Region.
             The Kansas RMP states that it exists to improve the quality and availability
             of health services to people within the Region.  Functioning within the
             framework of regional cooperative arrangements, the program has  designed
             planning and operational components which "create an environment favorable
             for recruitment of critical health professions and assure these  professionals
             career satisfaction aad prominence in their locations" in each subregion.


                                       DEVELOPMENTAL COMPONENT


             First Year                    Second Year                    Third Year
               $163,360                     $201,134                       $234,628

             Developmental activities,described in the application are largely extensions
             of ongoing Core activities and are generally related to the Regi6n's seven  I
             objectives.  More specifically, the Region plans for use of the developmental
             component funds include the following:
                      Data Requirements - For the past three years, KRMP hat been co-
                      sponsoring and jointly funding with CHP a study.t6 provide a broad
                      data base for planning purposes, and the Health Manpower Information.
                      Further development is plann6d for cooperative studies relating to
                      health manpower, personal health services, and facilities.
                      Manpower Training and Continuing Education - the Region has established
                      working arrangements with both UKMS and the Wichita State University
                      College of Health Related Professions (CHRP).
                           a.  Regarding the first, emphasis has been placed on the
                               development of affiliated health education and resource
                               centers as part of  regionalization  efforts.  Developmental
                               activities, involving a potentially large number of medical
                               communities seeking affiliation, will consist  of  extensive
                               planning, initiation of education  programs,  communications
                               support systems, and related activities.



       Kansas                                -10-                     RM 00002  5/71

                      b.   The working relationship with WSU will  concentrate  on
                           development of an expanded role for the CHRP in planning
                           and implementing education programs which are coordinated,
                           multi-institutional, formal and continuing education programs
                           for@health-related professions, and in analysis of present
                           projected curricula.
                      c,   Closely associated with the WSU effort, the Kansas Hospital
                           Association and KRMP are cooperating in the development of
                           a Personnel Development  Program  involving,"inservice"
                           programmed education in Kansas Hospitals for related health
                           professionals, pre-professionals and other hospital
                           personnel.
                  Community Programs - Two community-oriented activities of the KUMC
                  Department of Human Ecology are of particular developmental interest
                  to the Region:
                      a.   A KRMP proposal to assist in defining a health care plan
                           for the immediate area to improve accessibility.
                      b.   A medical student preceptorship program  to  facilitate
                           movement of students between institutions.
                  Four-level System of Medical Care - In June 1970, the Kansas Medical
                  Society passed a-resolution proposing a special study and recommending
                  approval'in principle of a four-level system of medical care suggested
                  by the editor of the Salina Journal, Salina, Kansas, at the 1969
                  State Medical Meeting.
                  The system would consist of:  1) routine, immediate care in smal I
                  towns by "superior nurses, o erating@under the  direction  of  a
                                               p
                  physician; 2) physicians practicing in larger towns in cooperation
                  with nurses.in small.,towns, and skilled nursing homes; 3) physicians
                  (including specialists) in regional centers with fully equipped
                  hospitals, laboratories and nursing homes;. and 4) a broad range of
                  facilities and specialists as at Wichita and KUMC, interlocked with
                  with  State institutions and the Research center.
                  The  Region views the study of such a four-level system as providing
                  many  Areas for mutually usefull activities by KMS and KRMP which
                  could be funded through a developmental- componet.

       ,Administrative Procedures for Allocating Developmental Component Funds
         Contracts will be executed on approval of the entire RAG, and expenditures
         approved by the Director or his designee.

         PRES@-   APPLICATION                                      Requested
                                                                   Fifth Year
         Core                                                     $I,,171,410
         DL.ring the Dast year, the core function has been reorganized to consolidate
               -   . --- ---I --         corn nf t-'hp Atibrpgional offices from projects




              Kansas RMP                                                     RM 00002  5/71

              to core.  It now has six central   sections  and  nine  subregional  offices.   The
              central core offices, coordinated by the Office of the Director, include
              to   following:
                        1.  Office for Institutions and Administration - provides liaison
                            between the central staff and nine subregions and develops
                            working relationships  with  the  Kansas  Hospital  Association  and
                            health-related institutions.
                        2.  Office of Continuing Education - provides assistance in planning
                            continuing education  policies  and  strategy,  in  cooperation  with
                            the Continuing Education Planning Committee and Continuing
                            Education Policy Board.
                         3. Office of Nursing  -  stimulates  educational  programs  for  nurses,
                            both at the local and university level.
                        4.  Office for Related Health Professions - develops at the regional lev(
                            pilot  activities,  feasibility.studies  and   educationsi@@iog-rams
                            and at the subregional le              in-dev'eloping   pr-ojects   anJ
                                                       vel assists
                            locally planned educational activities in the related health
                            professions.
                         5. Office of Research And Evaluation -.develops models of evaluation
                            for project directors and  a  planning  and  evaluation  strategy  to
                            permit program assessment.  The Office of Health Manpower
                            Information Program, with responsibility for data collection
                            and analyses, is also included in this Evaluation sect on.
                         6. Office of Special Services - provide data processing and
                            communications services for the Region.
              There are subtegional offices located  in  these  nine  locations  -  Kanias  City,
              Emporia, Wichita, Great Bend, Topeka, Chanute, Colby, Garden City and Salina.
              Geographically  KRMPle  subregions  relate  closely  to  CHP  subregions.  Several
              of these core functions were formerly funded as projects and have been brought
              into Core auspices during the post year.  The personnel in the subregional
              offices work with both the Planning and operational activities And serve
              as executive secretaries to the Local Advisory Groups.
              Core staff has sponsored a  number  of  feasibility  studies  and  joint  planning
              efforts with other agencies.  Examples@ of these cooperat ve efforts include studii
              conducted withthe Wichita State University College of Health Related,Professions,
              with the Kansas Hospital Association, and with CHP.  A complete listing occurs
              between pages 98-127.
              There are 66 (61  full-time  equivalents)  positions  budgeted  for  1971-72;  all
              but one are filled.  This number includes 18 professionals and 28 secretarial
              positions.
                                                                           Sev nth Year
                             Sl.yth Year
                              $1,350,881                                    $1,620,083




                                                -12-                    RM 00002  5/71
        Kansas



        Continuation      ects
        Continu                    equested for the following two pr jects:
               ation support is r                                       0
                                                                    ues e@d
        Project #4 -   cIardiovascular Nurse Training            $136,441
                     Support  is  requested  to  continue  a  unified  in-service  training
        program for'nurses in  providing  care  to  acute  cardiac  patients  in  coronary
        and intensive care units.  The  program  has  trained  over  100  nurses  to  date
        in  six-week  courses  on  electrocardiography,  cardiopulmonary   resuscitation   and
        pharmacology of cardiac  drugs.  A  physicians'  course  will  be  offered  in  the
        spring of 1971, both to update physician knowledge and to overcome the
        problem of lack of confidence in KRNP-trainied coronary care nurses.
        The Region ranks this project tenth.  it is directed towards goal 2 (improving
        professional performance).
                                                                                      sted
        Pro ect #38 -  Basic  Continuing  Education  for  Medical  Record       $6,415
                       Clerks.  Funding   would support a 3-month continuation
        ,period to allow  extension  of  consultative  visits  beyond  the  present  funding
        period for this project.    Purpose of the project is to present -a basic
        training program in medical record science to personnel in statewide hospitals
        who lack, or  are  unable  to  have,  more  formal  training.  Consultative  visits
        are  designed  to  evaluate  on-the-job  performance  of  librarians  after  training.
        Forty-two trainees  participated  in  the  first  session,  with  post-test  score$
        indicating a 42% knowledge increase.      Second and third sessions were scheduled
        for January and April 1971, with similar objectives and format.
        The Region ranks this project #12.  It is directed toward goal       2    (improvement
        of performance).


        Ren            cts
        The Region requests additional    years of support for'these    six projects:
                                                                       Requested
        Project #lR - Great Bend Educational Program
                       Site  visit,  Committee  and  Council  action  are
        required to extend support of this project for two additional years.           The
        project which has  been  operational  since  1.967  requests  support  to  continue
        development of this comprehensive, subregional, model education center
        affiliated  with  the  University  of  Kansas  Medical  Center.  The  Center  provides
        physician  education,  nurse  retraining  and  allied  health  continuing   education.
        Proposed  activities  will  continue  with  some  change  in  emphasis,  including
        a  shift  toward  incorporation  of  linkages  within  the  subregion  and  evaluation
                                             tion with  the  resources  of  the  central  Core
        of the overall program in coopera
        staff'.
        This project is ranked first by KRMP since it addresses all seven of        the
        Region's revised goals.     It has resultbd in a contract between Kansas
        University  and  central  Kansas  medical  centers  and  working  arrangements   among



              Kansas RMP                       -13-                     RM 00002  5/71

              a variety of subregional institutions to carry out cooperative arrangements;
              improved technological and related health professional support for physicians;
              reduced previous restraints to shared practice; improved recruitment of
              physicians to the central Kansas area; and reactivated many nurses through
              the reorientation course.  The project has, through reassessment of delivery
              methods, increased both capacity --- with the development of home  health
              care services --- and quality of care through initiation of improved programs
              of care.  There has also been installation of communications, teaching and
              computer aids.  Finally, the project allows for experimentation and evaluation
              of its activities.
                Sixth Year                                          Seventh Year
                $110,446                                             $1,17,015
                                                                               Requested
              Project #8R - Continuing Education for Cardiac Care - Wichita     $39,526-
                           Funds will continue the support of a unified
              training course for nurses providing care of acute cardiac patients in
              coronary and intensive care units, and to provide continuing education for
              physicians.  To date, 265 nurses have completed the two-week's training, and
              more than 100 physicians have participated in the two continuing education
              courses.
              The Re gion ranks this project #ii.  It is directed towards goals 2 and I
              (improving professional performance and strengthening cooperative arrangements).
                                                                              Requested
              Project #9R - Metr(         nsas City turse Retraining        $320074
                           (Reorientation to Clinical Nursing Project)
              Support is requested to continue an interregional program of retraining or
              updating nurses for reactivation in the Metropolitan Kansas City area.
              To date, 133 have been trained. Of the first 84 participants,  747.  were
              working 12 months after course attendance.  The 17 participating hospitals
              have indicated interest in continuing the program and capability for assuming
              responsibility after July 1, 1971.
              The Region ranks this project #9.  It has provided spin-off in the form of
              instruction to teachers in outlying communities.  The project is directed
              towards goals 2, 3 and I (improving performance  modification  of  factors
              influencing distribution of professionals, and strengthening of cooperative
              arrangements).
                                                                               Requested
              Project #21R - Cerebrovascular and Neurological Nurse Training     @:36,.j45
                             Funds will continue support of a program providing intensive
              training to prepare clinical@ nurse specialists in the area of cerebrovagcular
              and neurological disease and trauma, and  provide other short-term training
              for upgrading nursing competencies.  Six enrollees have been trained to date
              to expand response and enrollment. The proponents  wish  to  shorten  the
              clinician course from 4 to 3 months, provide a variety of related courses
              varying in length and objectives, target the project towards other health
              professionals, and publicize the program to reach a larger audience.  The
              spring and summer of 1971. would be used to plan retargeting of the program to
              reach nurses in all of the mid-continent states.

              Irv,@ vocinn ranks this project #14.




        Kansas RMP                              -14-                    RM 00002  5/71

                                                                         Requested
                                                                      Third   Year
        Project #23R-Kansas Medical Library System                      $61,1-681
                      Similar action is  required  for  this  three-year  request.
         Future support  is  asked  to  continue  development  of  this  system  -
        of  medical  library  service  designed  to  provide  ready  accessibility
        to health professionals.  Additional activities proposed include:
        education  of  library  personnel  with  limited   experience   initiation
        of quality  control  of  library  services,  completion  of  @he  revision
        of KUMC film  catalog,  publication  and  distribution  of  1,000  medical
        bibliographies to  medical  librarians  statewide,  and  the  securing  of
        future  financial  and  administrative  support  for  the  library  system
        in view of eventual KRMP funding termination.  This project is ranked
        third by the region, relating to goals 1,2, and 6 (strengthening coop-
        erative arrangements, improving performance, and improving communications).
        Fourth Year:  $68,846                               Fifth  Year:   $80,596


                                                                        Eeguested
        Project #32R-Institute for Dieticians.                          $12,000
                      Support is requested  to  continue  this  two-part  training
        program, sponsored by the  Kansas  State  University,  which  is  designed
        to update knowledge  of  therapeutic  dieticians  currently  employed  and
        reorient inactive dieticians; The program offers a 'one-week institute
        in therapeutic nutrition  and  a  second  one-week  institute  in  Dietary
        Department Management.  The summer 1970 session trained 21 in the first
        course and 17 in the second.  Both will be offered again in 19-71 with
        no basic changes in format or methodology.
        The Region ranks this project #13.  It is directed towards goal 2
        (improvement of performance).

        Approved but Unfunded Projects
             Projects.#40 - 44 were previously reviewed by     Council in November
        1970. No action was  taken  on  Project  #40  until  the  Council  had  an
        opportunity to  review  the  Kansas  RMP  Anniversary  Review  application
        and site visit findings.    Projects #41, 42, and 4 4 were approved, but due to
        national funding constraints could not be funded.  Committee and Council
        action on these three is needed in determining a funding level for the
        next year and not for approval of the activities.
        Project #40 - Development of a Comprehensive Nephrology Program
                                                                         Requested
                                                                      First   Year
                                                                      $133,678
        Action on this project was  deferred  to  a  later  Council  so  that  the
        site visitors could review  the  proposal  in  light  of  the  total  KRMP




                                                    -15                       RM 00002  5/71
              Kansas RMP


              program and statewide efforts in kidney  disease.  The  Region  has  just
              terminated a renal disease training program, Project #37, Care of Patients4
              with Fluid, Electrolyte and Renal  Problems.  The  Region  is  presently
              negotiating with the Missouri and Bi-State RMP,'s to  develop  a  multi-
              regional renal program appropriate for 910  funding  (p.166)  for  sub-
              mission March 1, 1971.
                      This project,  IP40, would be implemented  in  three  phases.  In
              the first phase,, a six-week training course in  center-based  (or  back-
              up unit) dialysis for communit- hospital  nurses  and  technicians  will
                                            . y
              be developed and implemented, and a series  of  courses  for  physicians
              will be developed to update knowledge of renal  care  and  improve  inter-
              action of physicians and  nurse  nephrologists.  Existing  KUMC  facilities
              will be expanded for all training.  In  the  second  phase,  physician  . I
              training will be implemented and training of Nurse  Nephrologists begun.
              Hospital administrators will also begin training  in  both  funding  of
              treatment and accounting procedures.  In  the  third  phase,'With  planning
              already completed for coordinated renal prevention, detection and
              treatment, Nurse Nephrologists will be introduced  into  the  care  system.
              Future sponsorship for the project will also be  arranged  at  this  time.
                      This project is ranked seventh  by  the  region,.and  is  directed
              toward goals 4, 3 and 2 (training  of  new  and  underdeveloped  health
              professionals, modification  of  factors  influencing  distribution  of
              health professionals, and  improvement  of  professional  performance).
              Second Year: $108,081                             Third  Year:   $li4,746


                                                                            Requested
              Project #41 - Cancer Information Service                     $82,803
                            This project would establish a uniform and complete
              computerized central cancer registry  to  replace  costly  manual  systems
              now supported by only a few hospitals  in  the  State.  Support  of  par-
              ticipating hospital registries will requirp education of medical
              records personnel and periodic auditing  of  abstracts  in  the  hospitals
              by a traveling medical record librarian or expert cancer registry
              secretary. Other  activities  will  include:  provision  of  cancer  con-
              sultation service, study of the value  of  a  newsletter  in  disseminating
              information on available  registry  data,  education  and  computer-aided
              instruction, study of the value of a  central  registry  and  a  tissue
              section repository, and A p  ilot study on means  of  extending  cancer
              education in Kansas.
              The Region ranks this project fourth.  It is directed towards      goals
              1, 2,.and 6  (strengthening  cooperative  arrangements,  improvement  of
              professional performance, and im rovement of communications facilities,
                                               I p
              equipment and related techniques).

              Second Year: $88,358
                                                                 Third Year:    $101,314




               RMP                                                       rwi vvv%j4. @t

                                                                         Requested
        Project #42 - Cancer Care Continuing Education Program           $64,262
                       The purpose of this project is to train RN's. LPN's
        operating room technicians, and families of cancer victims in    the
        etiology, diagnosis, and treatment of cancer;  and  to  develop  a  coot-
        dinated hospital and home care program to serve the subregion.  Evalua-
        tion procedures will be designed to record both knowledge and attitude
        changes in trainees and development of the hospital home care program.
        This project is ranked eighth by the  Region,  and  is  directed  towards
        goals 2 and 1 (improving professional performance and strengthening
        cooperative arrangements).
        Second Year: $70,957                                   Third Year:   $72,172


                                                                               sted
        Project #44 - Nurs6 Clinician Program                             $125,212
                       The purpose of this proj'ect is to  train  nur.sea to act
        in a primary therapist's role in  the  medical  management  of  patients,
        as a remedy to physician shortage  and  maldistribution,  and  lack  of
        accessible, comprehensive services.  The two-part program would consist
        of an eight-week core program and a  six  to  ten  month  preceptorship
        program.  The core program is designed to train a maximum of 120
        clinicians after three years, with four classes per year.  Each trainee
        must  have physician or agency sponsorship with a guarantee of employ-
        ment  after training.
        Upon  completion of the core program trainees  will  begin  a  preceptor-
        ship  to develop in-depth knowledge and expertise in management of
        care  under a physician's tutelage, and in a variety of possible prac-
        tice  settings. It is viewed  as  potentially  providing  a  comparison
        study with programs elsewhere in the nation geared to developing
        physician assistants. The project  is  directed  towards  goals  4,  3,
        and I (training new or underdeveloped health professionals, modification
        of factors influencing distribution of professionals, and strengthening
        cooperative arrangements).
        Se ond Ye@r: $122,183                                  Third Year;  $126,155

        Supplemental Project.:
                                                                              sted
        Project #45 - Model City Health Manpower Education and            $37,290
                       Recruitment Program.  The purpose of this project is to
        raise the level of knowledge and understanding among Kansas City,
        Kansas  model neighborhood residents about good health practices
        and to provide a means of their entry into health professions as
        health aides, while at the same time easing the health manpower
        shortage and Access problems prevalent in the area.  Under supervision
        of a health coordinator, six health aides  will  be  involved  in  class-
        room instruction on community health, practicum activities, and supervised
        activities involving communication with  and  teaching  of  residents  in



            Kansas RMP                            - 17 -                     RM 00002  5/71


            need of education or services.  A Model Cities supplemental grant
            will provide the trainees' salaries.  Another Model Cities project is
            being funded by Missouri RMP in the Wayne-Miiier area of Kansas City,
            Missouri.
            The  Region ranks this project sixth.  It is directed towards goals 3
            and 4 (modification of factors influencing distribution of profes-
            sionals and training of new professionals).
            Second Year:     $37,290                              Third Year.:  $37,290

            Terminated Projects    (6/71)
                     Project #24-  Food Service Personnel  Using Dietary Consultant
                                   Approach
                     Project #37-.Care of Patients with Fluid, Electrolyte and
                                   Renal Problems





































                                                                                   GRB/2-17-71







                                                                                    KAXSAS RC.GIOXAL MEDIC,IL PROGRAM SUBREGIONS (AND DATES ACTIVITIES IJERE. I.NITTAZED)
                                                                                                                         17

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                                                                                                                                                                     VII     No,rth@iest
                              I    Northeast                                                       :V  Flin,@. Hills
                                                                                                                                                                   VT
                                                                                                    V  Cen-tral                                                        II    iNorthcen@6ral
                            IT     Southeast
                          T                                                                                                                                            IX    Capitol
                                   Sou'6hcentra'i                                                  VI  South%iest




                                                                KR L@ PRO                                     REVIEW PROC@SS
                                                                                             JECT


                      Es t', tnated
                           Days                                                                             C@;P             Technical Adv@sor
                            to                         @KRMP                                                             'Vied 1                                           DR-1-
                        Con.;>Iete                  Exec.   Cor.1m.                 Lead                A          8        0                    T                 ua-  Grants
                         Staqe       Proponents         Staff        RAGI, L                  RI                Agency Hea                                         n     Review




                                         On
                                         o@j

                                         0
                         .60              0
                                         0 03

                          65
                                                                                                                                                             :CT)

                         90,
                                         .oo

                        100              0
                                         00
                                          o@-
                         t.0




                         130
                                         0
                                          0
                                         00


                           KEY                   Document    flcrei              Review of     project need             I.nforrlation                 /S?     Decision to su    -bmit
                                                                                                                                                              project to DRVP
                                                                                                                        Decision to    continue
                                                 Docu-..,--n@ f icv              Review of     Prcec,                                                                ion to fund
                                                                                                  J
                                                 w;icn     required       @T     technical     as;act@                  review process                        PI Or Coil se c t
                                                                                                                                                     IFI






                                                          -20--



                                     DEPAr@-i't/41:j'll' 017'                         AN[) WLLFAr@f--'

                                       1-iF'ALTFI St-F4VI(';F.'S AIJI-) MENI'AT- FIEALTH AO?AINIST,@tTION


           Date:     February 16, 1971
        Repty to
         Attn of.
                     .':'t@iff 1'evievi of tire Triennial A-,)plication fzo.-@i tiie Y@,@n-r,,as ilcr@iorial
         Subject:    I-ledic.-.1 Pro-rc-t-.i    2-05

             TO:     i@.ctinc, Director
                     regional 'eledical Pro-rppln Ser
                                                 u
                                   Cliairtiall of the


                                   Chief, Grants Revie

                                                 ii t s 14,? n z        'ri
                                   Chief, Gr                           L    ri cl-i

                                   Actina Chief, Rsfional

             Staff riot to revive,,? the triennial cii.)plicat@-on                             I-,y the  l@lansar,
             Medical Pro-ram.          A primary                 o'L ties reviei; v;@is to identify arid r-liscuss
             issues for the site visit on ll,,arcli 4-5.                 Sitici,, only   t@.;o projects have co,.-I-.
                          and this i@ a  triennial look, clel:'Lb--ration of the cotititki-iatioi-,
             of Llic application sce-@iod superf tious.
             The application requested the following total costs for the 05 year-.

                      Core
                      ConLiliuntion Projects                                     181,5
                        f4  and   fr'3u'
                      1',eno.,Lil -Projf,-cts                                       400,746
                        Cs  1, 8, 9,  21,  23,        32
                      Previoi.,,@,ly AT,)I,-co,.?@ei/Uofuneed                       471,037
                             40, 41@, 42, 44
                                Projects                                           37,290
                      Developiacntil Cc:7iportont
             TO""P.L                                                             $2,750,577

             Sir.c(@            %ir3L, or,,e of tlie fil-rt                to Ilse tire
             staff    b,,-,--@n  the
                         L
             and problc,;--@s the- for!,is                   and nbo,@.it 1,1@),,-?               LISC!D  t"@,@-Tn.
             1.      .';taff a-rec@d tlilt the foi:.-,r, pi.-esentccJ, p,@-iod cc)P.Aci@rc                       of Core
                             0
             fe,is@@.bility   rtt@idier.    atici    projects       Llia@L        f.-Acilitz-ltc-cl tiz;c of tt-t@a
             de,@ci.-ipto).- fori.-to f,)r the                           ti-ir, otii,,?.r
                     ;.,nl on projr-c,..-.r,       it e-.@4ffi.culL  to
                           ar@ plitili@rl,                        of     Io                      t@,
             the     J.ffcrcflct--  it
                                                                                            of- tic-altl
                                     @-rd  the              uc,@-cl  to C.;,, -,,y
                                                                                                             2.        I
             the     local r(--vici? p@cccf, 111'.@,
                     n   L:.@; to  tt  i   qt@@-  L I,,,) ri n              r)c,           i i@Ae (@l -(it -.-I Cy  o
                                                           to
                                    of





                                                      21-




        the Re-ion ivuld disc,-z@-@-           ovc.-,Ill s@ri@c-@y n ..a or prograL-1 areas, sucli,
                                                           0-       A.
        as continuing education.         In the l@linons progr@@.i  by far   the largest nu@mber of
        projects and nirount of money       are invented I..q continuing education.          In the
        past, fraomeritation of these       activities hns given cause for conccrn about a
        coordinated plan in this nrea.          in this application, the sense of fra,,-.iont,,ition
        is ff-trt:licreet 'by the         pic-cciac,.il -ipproic'ti to the pro-rnm throu@,h the
        discti-f,.ion.q in terr:ts of                   with or,,.inizf'.tiolis, I)rojccts and core
        fe,ir;ibility             rather Lilin as a wiole.        As ,t consc.@cl,,iciicc-, stiff t;@-14
        the ne.@d for info::i:,.ition of tt-iis rcrt bcin- either requested in the application
        or in an interini position popzr v.,Iiicit cotild b@- r@,ade available for the site
        visitors and other rovi.ci.-zrb,.      4. 'i@icro is no ovcriill- bidet picture givin,-,
                                                                                L)
        totals for the 02 aLid 03 yeirti and riibtot,-ils for core niid projects for all
        years.    Becf-,iase the progrzi-.i had  to  be  writtc!n  to  provide  this  info  m.  ation  the
        IIIS could not have the. infoiritio.,-i availil)lL, Li.,it3.1 the ti-@-12 of the meetinc,.
        Staff, therefore, did not have it available for                      individual study and
        thus li@id to cILiplicite the systc-,.i's effort.- i.,- order to l'oo!,, at the fiscal
        side of. the Recioit's request.                        etiny     Indirect   Cost    figures    are
                                            prior  to   tLic
        not available for the 02 and        03   years   for   b@id-et   projection    purposes.
        5. Since no geographic or dc-.o@ral),%Sc data              provided,    staff     needed to
        call the Region to get the information.
        Thus, x,,hile KansaG has made fairly good          tiGe  of  the  forLis,  it   involvesa
        special Charlene to staff in providli.n-           additional material for the site
        visitors  which  N-iill  highlight  the  issues   and   present   a   clearer   picture   of   the
        KanGas program.
        I'he f-olloi-iiii&! is-,ties and questions for tiie site vinitors and          national,
        revi-c-,2.:!rs h,-ive been grotit,)cd z,..ccordiiig to the cate,,orie@- of the            Rev-.'Lc-ii
        Criteria.


                1.  Coal     0   @c 3 V C, -q
        Kansas has outlined seven objectives ind given each project a priority rahl-,ing
        purportedly based on its relition to the objectives.                lniit Is the c)ztcnt of
        the acceptance of these objectives and the priority ran'@in,, on the part of
        those associated x-7ith                  Staff, Locl] Advisoi--y                     PAG.  The
        Great 11@-nd procr@-m is rz-,nircci @."l and Dr. Bro-,,.,-'l x,,as the director  of  this
        progr-@,@-i before lie becivz-,o, Coordinator.

                2.         52--ati Pal Ef-f-l-c
                     a.   Coordinator - Dr. Broi7a,      %-;,to is well-!,no,,:n thro,,iclilo-Lit the @rt,-ite,
        is generally re-arded as a strono coordi.n"ltoi..            '.Llici:c. are so-;--- indic,-tti.oi,-
        froni core  qtaff  nc;jibcrs  threat  Dr.  1,rot;a's      of control in the
        riny be too restrictive.        As in              r,,"XS  Stiff  life.  le@ti-ned  confidentially
        that his staff are not peri-qitted to attend 1,;%G meetings.
                     b.   Core Stif'L - I-I,iit is the rel,-.ition,-'4i5.p bet@?cL,.-i the central core
        staff in Kan,-,as City ana      the sub,,:c-,iotial staff?          kind of a--r-.i,-,tincc
        tlic, cciltr@-I core provide    the -3,,ibrogi.onil coor(iinILO):S?          re,,zir(I Lo core






                                              22-



                                                 -3-

         c.-i,bil,,i Iit v qttid@- c-,@ : 11 I-", y is YT-@ st                         directly
                                                              ic-tivit-ie.!3 desi@n@Dd
         for ro,--dicil students and residents?   2)       is tti-@ need for three automated
         rp,edical record systeras (p. 110, 111,  117) -nd i.;I,@at is the relationship zLionr,,
         the  three? I,,'-hat use is     rial-,in3 of the lar-c @imoi-int of ongoing fork in
                                                            0
         this  area?

               c.  ornittcd - section in outline not applicable to discussion.
                                                           I

               d.  Pccional A..dvi.,;ory Group - To       extc,-.),t is this      a cr(:!,ature
         of the Coordinatoi-'s or an indep(@nclcnt c@,c-,it?  'ii-icre is one ni.irse, '.)to is
         affiliated %7ith tl)c U@iivc-r,,@,ity and no allied health representative on t@-e
         RAG. In viet@7 of the lir,-e proportion of  activities  involving  tl-te--e  gro,,tps,
         should corciderat-.;,on be given to increzisir.- this representation      Is there
         sufficient Minority -ro,,ii) (bl,-,ckc., Incli.@ir)s, migranti;) representation? Irnat
         provision is being aide for Iti@, rci)rcse,,IL:ition?        is there lii:ovision
         for local Advisory Groups' inp-Li@'t into the Pi'@G's decision risking,?
               el  O-,tbre@,i.on@liznt;i.on        I?'jll his nine sL@brc3j'-onal offices,
         ti@o of %7hicli Hill be visited by tll(-@ site visit thin (Greif- B(,n(i and ll'ic.Aita).
         Conce@tis i,,Iiicti staff brotl@l E: up for considerate n sre: 1) provi.(.'@cr and
                                     ,I                       0
         cons,@,,,ier acceptance of the cubre-ional pro-rartis; 2)                     iny
         chan,,cs in  direction  and  future  plans;  3)  functioning  of  the  local  advisory
         rotips; 4) the relationship betve,,-n s-Libro-.iot-ial core staff and projects
         either on3oit-ia or proposed) in the stibre-i.ons; and 5) li.n!ta-er. %.;ith the
  4pmedical schooloand other health i.notiLutio@ns; 6) spirtoff effects in terias
         of serving as the i-petiir, for the c-.tibl.J.ch,nent of           activities in
         the s-lirrot@iidin- arc-Li; 7) ho-t-) do the othc2r         vic-i, the C--,c.Lit E@--,id
         and         pro,@rz@,.-kis; and 8)    is the                              for
         decidin- ii'nbther a project fill be (lesiFned for @-i subregion or the entire
         Region? 9) in a subrecional project, %.into a-recs that a particular hospital
         serves as a focal point for the project?
         llith regard to the pro-r,@-.1 it Grc@-it Peid in particular, staff
                                 ,L,
         1) Is there any educator iiip,.tt in the des3.,@,,n of the educational pror,rc.--4s;
         2) I'tis ttic procr---i icttiilly rerultc(.l in the recruitment of
                        0
         health personnel to the area; 3) 1,T@iat is the participation of the LAGIS
         in goal setting?
         In reviewing the I-',Iichita pro-rz;,i, staff queric(l: 1) I-,"iizit is LI)c,,
         of the subrc-ional office to project -C'3, C,)ntiniti.ri@ J.'clticitioii f(-)].
         Care  at                    and I.,",IiL .1.@;cistziztce, if any, Leon offerec' to
         the             2)       ir, the rel,-iti.ono',iij)   the C!'IP(b)         in l,licliit,-t
         and tile Vi'ic',.Iita ct,iLe university Coll.cgc@ of      Pelated Prcifes:-.ior.Ls;
         3) 1',')'@7 had the Y,-"r, efforts t,iore do.,@lt N7ith the enrl.y secessionist I-,iovl-@
         on tile part of physician and ho-p'Atils?

               3.
         chool                                       cor)i-d-iniLor liic; t,@!,e;i
         0 cl-@.IT'-c tli-ir,, DtlcLl I:-@     r,-,.@sL of tile vac,-Incie.---- occurred on
  rscove staff .14'tcr tile l@,SL Coo'.retil-i;itnr left x.;!.tli                fic,,tl.ty





                                             23-







                                             -4-


                                           ion',
                                              .11 as
                                                  ,pcct of the procyr,    POw effecti
         pc3:connel and increasin- t:he subrcr,@
         have these efforts been, staff iondered. llitl-i the ' P-L3o 4 n trien tor a new CIIP (A)
                     r, %@;iat is the relationship with this aoency.
         Aoency Directo
                                                                Ilany references are
             4.             oi-        Prob
         made in the ap-       '-t-o-t-hc--c,;i7lZct;j.on of t , including a Ilealth 1-1-inpo@@r
         Information Pro"r,--,i based in 'fope'r@la and the Health Information Syste-@n funded
         by core. @!hat have these studies and surveyr, rlio@,m ibolLiL health care needs
         in K@insis and ho,.,7 has tl@is infor6intion been used to determine objectives
         and go..3).s, as %.YL-11 as project activities.  Staff noted an apparent duplication
         of- effort oL-t, core staff in collecting and analyzin- data -;i-tich rhould be
         inveoLir,@tcd (refer to appendices).
             5.  Procr@i.,-i IMT)I.C!,Ient;atj.on               Treat 1-inds of proposals
         are coiiing up tli@ Lill@ @f@revic-@7 procct;s          have been disapproved
         durino the past year?  I-;hat kinds of activities i;ould the develop-i--ntal
         cc,-I-L)onent fund?  V@iy has the region elected to renexq so many projects?
         vrnat efforts is the Reaion riiaking to fi@d other sources of support for these
         activities?
         As noted before, the Kansas program has a heavy continuing education c,-.iphasis.
         VTiiat role does the Continuing Edtication Co-@-nittee vis a vis the Director of
         Continuing Education and core staff, Dr. Risin,-,, play in determining this
         aspect of the program?  In the past, there'lins been a unilateral, rather
         thp-.n a r.@ulti--disciplinary or te@.zi i,2proacli to colitil-i,lip.- CaLiciti.on and
         trai-nino. Has the Pegionts approach to this            I-,'iiit is the role of
                v                                         k2
         Lead Cor.,%-!iittees in determining objectives and priorities in their respective
         areas of concern?
               6. EvaliLintioii - Staff   generally pleased x.,ith the Pc,.,ion's project
                                                ,L@rabl.c terms, prorress is evaluated
         evaluation. Objectives are set in meet
         accordingly and projects appear to be monitored by core staff.  I-ladels of
                0
         evaluation for project directors are also provided by the evaluation section
         on core staff.  Staff believed, however, that prograui evaluation needed to
         be strengthened.
         The followin,- staff inenibers attended the tiecting:
         Dona Iloti@-cal, Grintf-, rcvic-,.,, Branch
         Teresa Schoen, Planniti- & Evaluation
                      ky, Revionnl Develoi)7@icnt Branch
         Frant@ Zizlnvs
         Gerald Gnrd--Il, Grants
         Charlie Bariies, Grants I',,inagc,,-,,,ent rranc-li
         Lai-irc!,,ir,c Ptilicn, Grants innocent Branch
         Juli@l       Cot-itinu-Lno, Education Branch
         Bob  Chn         9     -    -il Lii'Lsoti
                --ibliss, Or aniz.-itioii,





                                               -24-






                                                  -5-

                   Kidncy Disease Control Pro-ril;ra
       Ted tooreil
       Joe Ott, Systei-,,,s Ilani@c,;:@cnt
       Joanne Oll@Ialley, Syste@-,-Is l,lanapc-@aent
       Harold O'Flaherty, Plankiing & I,'valuati.on
       Spiro I.Ioutsatsous, Pl@inriing & Evaluation


       Dona E. Ilouseal
       Public liciltli Advisor
       Gi:anto revieii Branch





                                                                                            (A Privileged Communication)


                                                  SUMMARY OF.REVIE@,l Al@'D CONCI,USIOL,@ OF
                                                        APRIL 1971  R-EVIEII CO@@III'Tl,',E


                                                     KANSAS REGIONAL MEDICAL PRO@-IM
                                                           RM  00002          5/71

                                    FOR CONSIDERATION BY MAY 1971 l@DVI;O'ORY COUNCIL


                 RECOI,E-IEI@IDATION:      The      Committee      recommended      that      this       application       which
                                            requests.:     1)     the     activation     of      four      Council      approved
                 but     unfunded     activities,     2)     renewed      support'for      six      activities,      3)      the
                 implementation of one new activity and 4)  a developiiic-iital  component,  be
                 partially supported as  follows:

                                                                   R E, Q  1,@T

                                    COI@IMIT-             DEVELO@ll@IN'Ei@L                   SUPPLE@,[E',-qTAI,
                 Y.C 2,@ r,         MENT                  CU@IPONENT                         PROJECTS                       TOTAL

                 05              $1,314,266         1/         163,360                          766,li47      2/            2,244,073
                 06                1,350,881        I/         201,134                          60r,,161.     2/            2il53,l76
                 07                1.620,083        I/         234.628                          61@@9.288     2/            2,503,999

                 TOTAL           $4,285,230                    599,122                       2,021@,8106                    6,906,248


                                               SITE VISIT AND k',O@li,,!ITTEE RECO,',',@,f@'si\'DATIONS

                                                          DEVELOPI@IENTAI@                                                  TOTAL
                 YEAR               STAFF                 COMPONENT                                                         COilIPOLiENTS
                 05                Deferred  to                -0-                                                       1,800,000 1&2/
                 06                Site Visit                  -0-                                                       1,800,000
                 07                Teir,,i                     -0-                                                       l@800,000  I,&-2!

                 TOTAL                                                                                                   .5,  00,00

                 l./   Includes core and projects #4 and 38.
                 .Z/   Includes  p--ojects  IR,  8R,  9R,  21R,  23R,  32R,  4.0,  l@l,  42,  44,  45


                 Critioue:         In  its deliberation,  tlic!' CoLT@iitittee  accepted  the report o   t  e
                                   site visit to the Kinsas Region on March 4-5,  1971.   Under the
                 dynamic    leadership     of     the     Coordinator,     Dr.     Brown,     this     Region     has     co.-ae
                 far      sin.ce its  early operational. years when University representatives
                 dominated    the     RAG,     its     faculty     occupied     tfie     major     Core     positions,     an
                 the     projects     were     generated     at     the     University,     if     not     actually     locat-ed
                 there.   The Uni.versity's  predominant  influence li,@s been                                           di.senQ--ced
                                                                                                                      y          0 @
                 frritit -the prograta.        In    line    with    its    growing    coTnriitinetit    to    the     recl,,'-,)nqlization
                 of    health    services    and    education,    @he    University    nc%@7    looks    to    PIIP     as     a






               KANSAS PdvIP                     -2-                   RYi.-OO002 5/71

               vehicle for subregionalization  of  medical  education  and  new  mod(-Is  of
               health care delivery.

               Kansas has severe  medical  manpower  problems  throughout  most  of  the  state.
               Most of the KR'i'IP's programs have been directed to  some  aspect  of  the  -
               manpower  problem,  usually  continuing  education  for  heal th    professionals.
                                                     C>
               While many  projects  continue  to  be  continuing  education -  oriented,   their
               emphasis has changed from that of  an  end  in  itself  to  ameans of fostering
               better health  care.  The  subregional  part  of  the  Kansas program,    which
               includesia local Advisory  Group  and  a  Core  staff  member in  each  of  the
               nine subregions  has  been  developed  in  order  for  people in  these   medical
               service areas to  determine  their  own  needs  in  improving health care.

               Part of the site visit team went  to  Great  Bend  and  Wichita  to  meet  with
               Core sta ff  members,  project  staff,  and  providers  and  consumers  involved
               with KP,@IP i.n these communities.  While early slibreai.onal.  efforts  were
               developed to desian models for the entire  Region,  the  visitors  i.-enort@(@d
               to Committee that the Region seems  to  have  learned  from  @Iii-s  experience
               that each subregion must determine its own model..
               The leadership for  this  program  lies  clearly  with  the  Coordinator,  who
               is A forceful administrator is respected tht-.oLirl-ioLit the  state  and  has
               apparently a firm grasp  on  the  Region's  problems  and  the  methods  needed
               to solve them. He has been successful in buil.din(,  11@IP  committees  brotirid
               existing groups established  by  other  a(,cncies,  rather  than  creating
               sbpatate falP groups. He has  established  a  very  capable  Core,  staff  whose
               members are involved  with  the  new  Wichita  State  University  Colle-e  of
               Health Related  Professions,  with  migrant  and  inner  city  health  problems,
               and in manv 8ubre ions providin- staffing for CHP  are,)wide  plaiitiiiic,
                                 g               c@                                     0
               groups. As 6 consequence,  RMP  is  becominc,,.an  integral  part  of  health
               services planning in Kansas.
               Dec,ision-making, priority-setting  and  review  processes  are  areas  of
               weakness  and  should  be  strengthened.  The  review  process  could  not  e
                                             t>
               evaluated since  it  is  still  on  paper.  The  policy-setting  Lead  Committees
               in various  categorical  areas  ate  still  just  being  organized.  The  RAG
               relies heavily on the  Coordinator  for  direction  of  the  Program  and  for
               setting  goals,  objectives  and  priorities.  Because  Dr.  Brown  serves  as
               the principal conveyor  of  information  between  the  RAG  and  Core  staff,
               Local Advisory  Groups,  the  lead  Committees  and  project  proposers,  the
               RAG is isolated  and  generally  reacts  to,  rather  than  initiates  program
               ideas.  The  communications  problem  attendant  to  Dr.  Brown's  key  position
               of filterer of information  has  afso  prevented  better  LAC  input  into
               establishment  of  regional  goals  and  objectives.  Committee  concurred   with
               the team's recommendation tLiat the Coordinator develop broader communications
               linkages among the  various  regional  groups  and  place  high  priority  on
               fostering a more independent  role  for  the  RAG.  At  the  same  time,  however
               the Region  shows  potential  for  securing  provider  support  and  establishing
               an organizational  pattern  for  the  regionalizatibn  of  improved  health  care
               delivery and health manpower education which Committee believes is
               valuable and should be encouraged.





             Y,ANSAS RMP                                         R@l 00002 5/71

             Committee had concerns about   the Region Is  priority-setting  and  decision-
             making process, whic h ranked  a computerized  cancer  registry  proposal
             (Project lt4l) higher then a Model Cities  health  aide  training  program
             (#45). The site visit team members'  present  at  Committee  indicated  that
             the hard decisions required   in coping with a reduced  budget  might  produce
             a different alignment of priorities and that  with  regard  to  the  tumor
             reoistry proposal, the Coordinator would probably be able to take
             Advantage of any funds available in  the  state  for  further  developmental
             efforts. Committee, thought  however,  that  their  reservations  about  the
             wisdom of allocating @',IP funds for the proposal should be communicated
             to the Region, since the  evaluation  of  existing  funded  computerized
             ke istries as related by.PMPS  staff  showed  Generally  inadequate  results.
               9                                          0
             pom itt6e suggested that the Region be  reminded  of  Council  policy  on
             tOw,dr registries, which states that RMP support  may  be  provided  when:
             they make important contributions  to  regionalized  improvement  of  patient
             care, they plan to disengage @IP funds  promptly,  and  RMP  support  is
             confined to organization, planning of output   and development  6'L  new
             methods and not major equipment purchases or operation.

             Committee agreed with the rationale for the site visitors' funding
             recommendation which would give the Region  some  funds  to  continue  the
             more successful ongoing activities and at the  same  time  apply  pressure  to
             the Region to develop new and  more  innovative  activities.  Because  of  the
             RAG's relative inactivity in the decisiot-making and  priority-se.tti.i-ig
             process and the latitude for developmental activities provide       or  in
             the Core budget, there was no dissent  with  the  site  visitors  negative
             recommendation on the developmental component request.

             Project #40 - Development of a Comprehensive Nephrology Tra@n
             Program, was reviewed by the Ad Hoc Panel on Renal Disease.  Comm ttee
             did not have access to the  Panel's  recommendations  during  its  review.
             The proposal had been reviewed in November  1970  and  deferred  until  it
             could be looked at by a site visit team in  terms  of  its  relation  to
             the overall program. While the  site  visitors  did  not  assess  the
             technical merit of the  proposal,  they  questioned  the  proposets.abbut
             the proposals relationship with other  programs  in  the  state,  the
             efforts of the RMP Lead Committee  in-Renal  Disease  and  the  proposed
             910 application to be submitted by  the  Kansas,  Missouri  and  Bi-State
             RMP'S. The team was satisfied  that  the  Region  would  coordinate  regional
             resources) seek to prevent duplication  of  effort  and  combine  efforts
             @for 1.31annin@ of a complete regional program. The  site  visitors  included
             funds for the proposal at a reduced  level  in  their  overall  recommendation
             for support.  Committee  accepted  the  recommendation.  The  Panel  deferred
             their decision because of lack of information.

             Panel Technical Critique: Because  the  Panel  had  been  provided  only
             a short summary of the proposal  and  not  the  complete  description
             originally submitted in August  1970,  they  deferred  their  recommendation.
             in Addition, they stated that  the  proposed  short-term  training  (severAl
             @days) for physicians has been proved inadequate for  proper  trai-.iing.  The
                                                                     I
             home dialysis training is not discussed fully  enough  in  terms  of  existing
             needs. present status of therapy and resources  in  details  of  design  and
             method.


                                                          'RMP /rRR






                                                       --ION, AND VVR-LFARE
                          DEPAR't'MENT Oi7 I-IE-:ALTi-1, EDUCA
                                        PUBLIC HEALTH SERVICE
                           HEALTH SERVICES A,4r.) MENTAL HEALTH ADMINISTRATION,


       Date: March 26, 1971



        biect' Kansas Regional Medical Program Quick Site Visit Report, March 4-5, 1971.

         7-0 -Director
            Regional Medical Programs Service

            THROUGH:  Acting Deputy Director
                      Regional Medical Programs Service




             I.  STRUCTURE

            The site visit was divided into two parts for the March  4  session  because
            of the importance of the 8ubregioiial program and the need to speak  to  the
            Great Bend and Wichita representatives in their  home-communiti-es.  A  list
            of the site visitors is attached. The site visit  was  structured  so  that:

                 1.  The Kansas City team (Dr. Schm 4dt, Dr. Weinbe g and Miss   Hous6a!,
                                                                    r
                     Miss Schoen and Mr. Maddox from  .staff) met with  the  Coordinator,
                     the RAG  various-Committoe members and representatives of the
                     University, CHP and others interested in RMP from around the
                     state, and

                 2.  The Great Bend-Wichita team (Mrs. Wyckoff and Dr.   Nic.hol.as, and
                     Mrt Z-Izlavsky and Miss Kula from staff) met with Core staff
                     members, project staff and providers and  consumers  involved  with
                     the       in these locations. After spending the  morning  in  Great
                     Bend and the afternoon in Wichita, this team joined the. first
                     group in Kansas City. The eni-@,@re team met with.Core staff on  the
                     second day.

            IT.  MAJOR QUESTIONS

            Brief  , the major concerns of thi.s site visit were: 1) the amount of
            control over the program-exercised by-the Coordinator; 2) the  represeiita--
            tion and decis,-on-making of the RAG; 3) KRMP's relationship with the
            Univ6isitv* 4) the adequacy of the technical. aspect of the  review  process;
            5) t   apparent programmatic emphasis on continuing education; 6) the
            in ol omen6 at the su@bregional level and the relationship of subre-gional
            progr ms and groups with the regional gr-oups and the statewide program;
            and 7i the relationship of KRNP  with statewide grou,,)s  such as ClIp.









             Page 2   Director, RMPS

             III.  FINDINGS AND PECO@NDATIONS

             Dr. Brown, the Coordinator, is clearly the pivotal point in the Kansas
             program at present.  He dominates the Core staff, and,the Regional
             Advisory Group is his creature. He serves as  a  filter  for  communications
             between the RAG and Core staff, Local Advisory Groups    categorical  Lead
             Committees and project proposers. As a consequence,  the  RAG  is  isolated
             and fairly weak and generally reacts to, rather  than  initiates,  program
             ideas. This amount of &ontrol can be rationalized  somewhat  by  Dr.  Brown's
             need both to shore up the program after the last  Coordinator  resigned  and
             to disengage the program from the medical school's domination.
             While Dr.  B.rbwnis control of the program may be justly  criticized,  he  has,
             however, several major accomplishments to his credit.. He  has  assembled  A
             very capable Core staff. He has the  cooperation-of  the  appropriate  state-
             wide groups and has been even more effective in  working  with  individual
             Physicians and hospital administrators in getting things done.  As in,
             many Reg3'.ons., RMP has been on the scene longer than CHP and has consequently
             been more. successful in garnering support at the local level..

             Dr. Brown has also been very adept in  building  MT  technical  committees
             arou d existing groups established by other agencies,  rather  than  creating
             ,separate RMP groups. Examples of such efforts are  the  Pulmonary,  Renal
             and Cancer Lead Committees.
             The Coordinator also seems to be directing  increasing  attention.to  health
             services delivery, and there is evidence that he is in contact with
             those in the ReRion who may be developing health maintenance organizations.

             The site visitors commended Dr. Brown for taking advantage  of  these  kinds
             Of opportunities but they also recommended that he  involve  the  PkG  and
             other regional groups in more of the decision-mak'lng so that  the  program
             would be less of a one-man show.

             The technical aspect of the review process is still on paper, but is
             expected to go operational this year.  Provisions have been made for    CHP
             comment.

             In Great Bend, the multi faceted education program for  health  care  persoi@
             nel is making Progress. Particularly impressive  is  the  R.N.  retraining
             p ogram,@whicb returned 55 nurses to active employment out of a total
             enrollment of 65 in the course. While the Great Bend  project  has  not  been
               le to recruit more physicians to the area, it has helped those practicing
             in the Great Bond area by arranging for individual consultation on
             difficult cases by K.U. medical center personnel.  Leadership  in  the  Great
             tend area is distributed among the director of the Great  Bend  project,  the
             s  regional Core staff and the Local Action Group,,coTrprised of multi-agency
               d professional repr6sentatives@@-as,well as consumers. The LAG  has  been








             Page 3 - Director, RNPS
             p rticularly active in helping to identify and involve local people in
             the RNP sponsored educational activities.
             The subregiotal Coordinator in Wichita has developed excellent    working
             relationships with local project  directors  and  with  health  professionals
             in surrounding counties.  He has brought about stronger ties with the
             State Medical Society and has been instrumental in achieving better
             relationships between-physicians and hospital groups*
                      I
             He has also been a prime instigator in the.establishment of the new
             College  oIf Health Related Professions at Wichita State.University.
             A weakness of the Wichita Core operation  was  the  data  collection  efforts,
             which so far have not provided information  which  is  applicable  or  helpful
             to RNP planning. The Wichita subregion  also  has  a  mature  and  functioning
             LAG, which relates well with the CHP (b) Council.
            .LAG representatives from both subregions  indicated  that  while  they  have
             informal communications with the RAG through Core staff and, in one
             instance from a RAG member who also is on the LAG,  some  better  method  of@
             formal reporting of RAG meetings,such  as  written  reports  bf'RAG  meetings,
             and of getting,LAG input into establishment of regional goals to be instituted.

             After discussing their experiences in Great  Bend,  Wichita  and  Kansas  City,
             the site visitors realized that  the  continuing  education  and  subiegional
             activities, rather than being ends in  themselves,  had  been  developed  to
             regionalize health services for improved health  care  on  the  local  scene.
             Core staff and Local Advisory Groups were   developed in  order  for  people
             in t@'nese medical service subregions to determine themselves what they
             neectp-@. One of the biggest let3,sons the Region seems to  have  learned  from
             the   eat Bend and Wichita experiences was that  the  model  for  each  sub-
             region should be "what each subregion wants to do.   11
             In@line with  the  subregionIa.1 concept the Univeksity is now looking to
             as@the vehicle for subregionalization of  medical  education  and  new  models
             of health care delivery rather than, as in the  early  days  of  the  program,
             using-@RNP as a funding source for continuing education programs out of
             the medical center. in allied health, the  R-MP  will  support  and  utilize
             the resources of the newly developing College of Health@Related Professions
             at Wichita.State College.
             The team concluded that the Rc-gionhas  made  significant  progress  since  the
             last site visit.  They are developing a subregioaal program using
             tonti uing education as a vehicle  designed  to  improve  health  care.  The
             most;significant need is for the  Coordinator  to  develop  broader  communica-
             t@ions linka-aes among various regional groups ('@%4C, LAG, Lead  Committees,
             etc.) apd to foster a more independent role for the RAG.





            Page 4 - Director, RMPS

            The funding level recommended for the Region"S fi.ftl-i, sixth and
            seventh years is approximately $1.8 million (direct costs).  Because
            @lthe RAG is not an active enough participant in the decision-making
            process  the developmental component request was disap roved.
                                                                   p


                                t-,4

            Dona E. Houseal
            Public Health Advisor
            Grants Review Branch











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


            MAINE'S REGIONAL MEDICAL PROGRAM             RM 00054  5/71
            Medical Care Development, Inc.               April 1971 Review Committee
            295 Water Street
            Augusta, Maine  04330

            Program Coordinator:  Manu Chatterjee, M.D.

            This Region was awarded $904,473* for its  ni  operational  year  ending
            September 1971.  The Ol year award included indirect costs of $1,976,
            which rprresents an average indirect cost rate that does not even
            ap"roach one percent. The  current  application  requests  one-year
            supplemental funding of $27,896 from the Model  Cities  earmark  to
            conduct a program in Family Nurse Associate  Training  which  will  have
            an impact in the Model Cities areas of Portland and Lewiston.






                                        FUNDINC HISTORY


                                        Planning Stage

            Grant Year                 Period                 Funded (Direct Costs)

               01                   5/67 - 4/68                  $193,909

               02                   5/68 - 4/69                    358,170



                                       Operational Program


                                                          Funded        Future Commitment
            Grant Year             Period              (Direct Costs)     (Direct Costs)

               01           7/68 -  6/69               $  428,106             ---

               02           7/69 -  9/70 (15 mos.)      1,229,634

               03          10/70 -  9/71                  904,473*            ---

               04          10/71 -  9/72                                    $637,642

               n5          10/72 -  9/73                                      57,133


              Reduced to  $868,592  (see footnote on page 2)





                                            -2-                       RM 00054  5/71
           Maine RMP


           maine's Regional Medical Program received one of  the  first  anniversary
           program site visits in October 1970, and was enthusiastically recommended
           for developmental component funding by the  site  team,  Committee,  and
           Council. Supplemental funding for two new  projects  was  recommended  as
           well, for a total 03 funding level of $1,304,969 for this Region.
           Financial stringencies, however, have prohibited  the  awarding  of  new
           funds, and this Program is operating at its  previously  committed  level
           of funding, as follows:
                Core                                         $440,496
                Guest Resident Program                        30,940
                Kennebec Valley Regional Health Agency        171,144
                Smoking Control Program                       37@538
                Coronary Care Program                         146,812
                Physicians' Continuing Education              56,228
                Regional Library                              21,315
                                                            $904,473*



           Regional Objectives
           Maine's Regional Medical Program and its  Regional  Advisory  Group  have
           isolated six program objectives.  In priority order these are:  1) experiment
                                                                  vantaged   areas;
           with new methods for delivering health   care to disad
           2) develop new health manpower; 3) improve and update the level of     medical
           knowledge; 4)'develop  subregional  capabilities  for  area-wide  health
           planning and the delivery of health services; 5) maximize the capability
           for delivery of quality medical care  through  community  hospitals;  and
           6) maximize the capability for providing diagnosis, treatment, and medical
           educational leadership in referral hospitals.

           October 1970 Site Visit
           The prologue to the site visit report gives a good summation of the sentiments
           of the Committee, the site team, and the  Council.  about  this  Region.
                 The site visitors saw the evolution of  Maine's  Regional  Medical.
                 Program as being remarkably consistent with  that  of  the  program
                 at the national level - starting with a categorical- emphasis
                 but expanding to include a clear  commitment  to  the  development
                 of an integrated system of  medical  care  which  provides  access
                 to medically depressed populations as well as improvement of
                 availability of care to the c*mmunity at large.  The six program
                 objectives identified by the Region, and ranked in priority order
                 by the RAG, reflect this emphasis, but  also  are  geared  to  the
              Because of RMPS fiscal stringencies, the amount of money available to
              Maine during its 03 year has  been  reduced  to  $868,592  (including
              $50,693 carryover). Rebudgeting  among  program  components,  however,
              has not yet been c
                                ompleted.





            Maine  RMP                       -3-                       RM  00054   5/71


                 unique needs of Maine itself.  The  progress  MRMP  has  made  to
                 date appears goo,], with some peaks.of excellence and few valleys.
                 Essentially, the Region has been carrying out the public health
                 functions of  the  a-tate. The visitors  were  impressed  with  the
                 sincerity and effectiveness of the Coordinator  and  his  core  staff.
                 With the few exceptions described in the  body  of  this  report,
                 the role of the Regional Advisory Group indicates the readiness
                 of the Region to receive and administer developmental component
                 monies.  The Regional Advisory Group is established as the final
                 review authority and comfortably occupies a policy and decision-
                 making position. MRMP has developed  good  and  productive  rela'tion-
                 ships with other organizations in  the  state.  In  general,  the
                 site team thought this Region possessed the regional maturity,
                 the capabilities, and the  appropriate  management  abilities  to
                 make good use of developmental component monies.
            The site team did suggest, however, that the Region take steps to:  3.) change
            the character of consumer representation on the RAG to include n6n-medically
            oriented consumers and those of modest means;  2)  develop  a  subcommittee  or
            task force structure for the Regional. Advisory Group; and 3  clearly separate
            the functions of.the Board of Directors from those of the Regional Advisory
            Group.

                                                                        01 Year Request
            Project #20 - Family Nurse Associate Training Proposal.        $27,896
            This proposal is related to the first two program  priority  areas  of  the
            Region:  1) experimenting with new methods far delivering health care to
            disadvantaged areas; and 2) developing new health manpower.  The goals of
            the proposal are:

                 1.  To increase the depth of skills, knowledge, and understanding
                     of specially selected family-oriented nurses.

                 2.  To provide more effective  and  comprehensive  management  of
                     family patient care with physician direction in the home, the
                     clinic, and other community settings.

                 3.  To relieve the stress and pressure on existent systems and
                     facilities delivering health care.

            The application states that this wil.]  complement  an  existing  RMP-supported
            Pediatric Nurse Associate program and should be followed by an OB-NA program
            to complete the trilogy.
            Six Registered Nurses (four of whom will come from Model Cities areas) will
            participate in the first course.  The year-long schedule includes four months
            of intensive training and eight months of field supervision.  Six hospitals
            and agencies (including the Model  Cities  Neighborhood  Health  Station)  have
            offered their facilities for use in the clinical portion of the program.
            Irogram evaluation will be the responsibility  of  MRMP's  Division  of  Evalu-
            ition, and will involve a pre/post/foll.ow-up assessment.






                                                                    RM 00054 5/71
           ,Maine PMP

           The budget submitted to RMPS provides m8lhlY for personnel and consultant
           services.  Other sources of support, to include student stipends, are
           being explored.  If the first course is successful, two additional years
           of support will be sought from RMPS.  Efforts, will be made to build this
           training program as an on-going course of the University of Maine's
           Continuing Education Divis on..







































                                                                RMPS/GRB/3/12/71





                                                         (A Privileged  ConununitatIion)


                             SUMMARY OF REVIEW AND CONCLUSION 04
                                 APRIL 1971 REVIEW COMMITTEE


                              MAINE'S REGIONAL MEDICAL PROGRAM
                                       RM 00054  5/71


                      FOR,CONSIDERATION BY MAY 1971 ADVISORY COUNCIL



             RECOMMENDATION-,.Additional funds be,provided for  thi,s  application..

                      Year               R6quest         Committee Rec6mmetdation
                       03                $27,896                 $27,896


             CRITIQ E. The favorable reports of the October 1970 site team and the
                      January/February 1971 Review Committee and Council regarding
             @ e.ac ompiishment and future potential of Maine's Regional Medical
             P ogram were recalled by the reviewers of Project #20     Family Nurse
             As 66i4te Training Proposal. It  was  agreed  that  this  supplemental
             ai)i)li 4ti6n for Model Cities earmarked funds was re 6         e
                                                                  1 ted to th
                   @s first two@priority areas: (1) experimenting with tow moth ds
             to,r delivering he ith care to disadvantaged areas, and (2) developing
            @n  health manpower.  The training of Family Nurse Associates was
     AM      s en as@the second step in Mainef8 nurse associate triad:  complementary
             t'6@ex@  ing RMP supported-pediatric NA and future obstetrical NA
             Pr gr


                  liu Chatteree was not present during the discussion of this
             aPlitati6n.

                                                                            GRB/MPS
                                                                         4/19/71




                                                           (A Privileged  Communication)




                              REGIONAL MEDICAL PROGRAMS SERVICE
                 SU     i OF AN ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION




            MISSISSIPPI REGIONAL MEDICAL PROGRAM         RM 00057  5/71
            University of Mississippi Medical Center    April 1971 Review Committee
            2500 North State Street
            Jackson, Mississippi  39216

            Program Coordinator:  Theodore D. Lampton, M.D.


            This Region is currently funded at $1,095,428 (d.c.) for its second
            operational year ending June 30, 1971. $320,241  of  this  amount  represents
            unspent first-year funds reauthorized as carryover into the second year.
            The Region currently receives indirect costs of $375,958  which  is  32%
            of the direct costs award.  It submits an application that proposes:

                 (1)  Developmental component for one year.
                 (2)  The continuation of core and seven projects for one year.
                 (3)  Three years additional funding for one project, CPR Training.
                 (4)  Three-year funding for two new projects, in hypertension
                        control and in renal diseases.  The latter activity has
                        been supported for an interim period throug  carryover
                        funds.
                 (5)  One-year funding for Phase I of a new project in Stroke
                        Rehabilitation.


            The Region requests $1,430,979    (direct costs) for its  third  operational
            year, $301,023 for continued funding of two new projects and one renewa
            project for the fourth year, and $301,189 for the fifth year.  The
            breakdtt chart identifying the components for each of the,.,three  years
            follows'.

            The Region's triennial application is expected next year at this time,
            when a site visit is planned. The Region  elected  to  request  developmental
            funding and new project funds to take advantage of the  planning  ahead  that
            has developed this year. The former coordinator  has  resigned  to  work
            full-time for the VA Hospital, but remains on the  RAG.  Dr.  T.D.  Lampton,
            who had been his associate, has been appointed as coordinator  of  the  RNP.
            The former Dean of the University Medical Center, Dr. Robert  Carter,  a  so
            left the area in the past year, and has been replaced by  Robert  E.  Blount,
            M.D., Acting Director and Acting Dean of the University of Mississippi
            Medical Center.

            During staff review of the application,  specifically  the  continuation
            portion, the following points were made that may be of special interest
            to Committee and Council in reviewing this application:




             MISSISSIPPI RMP                    -2-                  RM  00057   5/71
                  (1)  The Regional Advisory Group seems to be more active in
             developing the direction and priorities for the Regional Medical
             Program.  A roster of 14 new members, special orientation.for new
             members, and a workshop retreat were factors contributing to the RAG's
             functioning.
                  (2) The Core Staff has been  serving  in  a  broader  capacity  than
             before. Project review and  surveillance  have  taken  a  lesser  portion
             of time than before. Staff has been  involved  in  a  variety  of  joint
             efforts to develop activities  for  funding  from  other  agencies.  The
             trend toward full-time positions and greater emphasis on sub-area
             development were considered strengths for the future of this program.
                  (3)  Health manpower remains the Region's first priority, but the
             focus is widening from' concentration on numbers and upgrading of skills
             to include consideration of distribution and more effective use of
             minority populations as health care providers.
                  (4)  The funding request  for  new  projects'includes  medical  care
             costs, as well as training and. consultation  costs.  This  has  been  a
             recurring feature in this Region.
                  (5)  The RAG has not taken a clear stand on phasing out RMP
             support.  The request for three years  of  additional  funding  for  the
             CPR project is a case in point.  When this Region was originally site
             visited for operational status, the site visitors recommended two-year
             finon-renewable support" for the  CPR  Training  project.
                  (6) Staff's general impression  of  the  total  activities  of  this
             Regional Medical Program is that the program has been instrumental in
             providing consultation, training and service from the University Medical
             Center to all parts of the State.  The training has involved other
             educational institutions besides the University.  Projects include
             integrated training, patient care and consultation.

                                         Fb'NDING HISTORY


                                          Planning

             Grant  Year                    Period                Amount Funded
                01                        /l/67 -  6/30/68         $    454,206
                02                       7/l/68 -  6/30/69              648,607

                                           Operational
                03                       7/l/69 -  6/30/70           1,229,567
                04                       7/l/70 -  6/30/71           1,095,428

             The Region has been advised that its funding level for the upcoming year
             must be held to $884,037 due to overall budgetary constraints.













                                                                                                                                             P.ECION          MISSISSIPPI
                                                                                                                                             CYCLE     RM 00057   5171
                                                                                            "I@'(')UEST         03              PERICD



                                          0                                                           IT@@-V  OUS L'@   I   NEI%F
                                                               -ACTIVTT7.-S
                                                                                         @@AL         A  P R    @T F U N     :ACTIVII'TES      DIPECT         'T@,'; D T,',l E C     T- OT,,


                    CORE                                        $ 162 , 95  7                                                                $           .5 7         156.490    S              7

                    #1 R  Stroke      Care       T)emon.              131,094
                                                                                                                                                  1-31    094      56 92@,           188.022
                              mon.  & Training in
                                      ry Disease                     t5,                                                                          178,000          72.210            250.21.0
                    r2R         Pulmona                                  liuo


                    43 -  Postgraduate  Institute                  57,187                                                                          57.1-87         15,370              72.557

                    #5  -  Cardiovascular Clinic                   33,175                                                                          33,175           4,535              37,710

                                                                                                                                                                                                0
                    46    -    Coronary    Care     Unit           89,285                                                                                          28,135            117,42
                                                                                                                                                   89,285

                    #10     Ra?ietion            Therapy           45,422
                                                                                                                                             1     45,422          16,565              61,987

                    ,ill    Co'r,,.p.  Neurology Clinic            69,040                                                                          69,040          16,278              85,318

                    #16  -'Stroke  Rel,.abilitation                                                                                    05    1    2@5      05       -0-                42,505
                                                                                                                           $ 42.5

                                                                                                                                  200,739         206,739          69,309            270,048
                    @17 -  Renal  Disease Program

                                                                                                                                   70,790          70,790          1,0,@27             81,017
                    #18     H)rpertension Control

                                                                                                                                                   53,267           4.0-               53,267
                    -ISR    -.CPR    Pr     m                                       $53,267

                                                                                                                                   97,518          97,518           -0-                97,518
                    DEIJELOP@LNTAL            CO.MPONENT



                                                                                                                                             7
                                                                                                                                                                                                                   Ln


                                                                                                                                                                                                                   Ln



                                                                     $966,160       $53,267                                      $411,552    $1,430,979
                                                                                                                                                                $446,979
                                                                                                                                                                                       877,026













                                                                                                                REGIGI\   MIS
                                                                                                                CYCT,F,
                                                        B'RE,'-KOUT OF R---QUES-1        04             PE-RIOD

                                                                               I?REVICUSLY     1                                                   TO'.AL
                                                CO\TL                                                            I DIRE   T
                                               !ACTII










                     5


                   #6







                       #16
                                                                                                                       184,14'

                       #17


                       #18
                                                                      $42,470
                       #8R

                     DEVELOP'MENTAL                                                                                                              I







                                                                                                                                                        383,519
                                                                                                                       $301$023       $82,496
                                                                                                   '@;$258,553
                                                                       $42,470









                                                                                                                 05  rERIOD


                                                                                                                                                                                                     cn
                                                                                                                                                                                                     cn
                                                                                                                                                            'I' ALL      YEARS 1  ALL YEARS
                                                                                                                                                                DTR'CR         .1 TC-I@L
                   or                      AC-,-!@FITIES      '.R Z I,' A T, APPR. /LTiNFLrN'       CTI@'ITIES       DI,@F         I' LIIRECT   I  TOTAL

                                                                                                                                                i                 362,      57
                             On                                                                                                                                                     519,447_
                         #!R                                                                                                                                      131,094           188     Q22
                                                                                                                                                   ---            178,000
                                                                                                                                                                                    25@@i-0-
                         ,2   R
                                                                                                                                                                    57,187
                                                                                                                                                                                     57,187

                                                                                                                                                                    33,175           37,710

                                                                                                                                                                    89,285          117,420
                         #6
                                                                                                                                                                    45,422           61,987
                         #10
                                                                                                                                                             I'     69,040           85,318

                                                                                                                                                                    42,505           42,505
                          1   6
                         #17                                                                     $190,354         $190,354        $75,476        $265,830:@       575,236           791,067
                                                                                                    77@515                              193         89,708@t      222,715           256,585
                         #s,,                                 $33,320                                                33,320          -0-            33,320!       129,057           129,057
                                                                                                                                                                    97,518           97,518
                         DEVEL.








                                                               $33,320                          $267,869        '$301,,'89         $87,669       $388,858';     $2,033,191      :$2,399,093
                                                                                                                         JL





             MISSISSIPPI RNP                 -6                  RM 00057  5/71



             GEOGRAPHY AND DEMOGRAPHY
             Mississippi Regional Medical Program encompasses the State of
             Mississippi.  Mississippi is rural in nature and rather sparsely
             populated with its capitol, Jackson, as the axis.  Responsibility
             for the northern-tier of counties is shared with the Memphis Regional
             Medical Program; according to the RAG report, that part of the  State
             attaches itself either to Tennessee or Mississippi, whichever appears
             to its advantage; the two RMPs and staffs work together well.
             The Regional Medical Program relates program development to the
             Comprehensive Health Planning and Economic Development districts where
             possible, but RMP activities are not bound by these areas if others
             seem more appropriate.
             Mississippi's health, education, and economic plight is a matter of
             public record. It is down at the bottom of the list in the  ratio  of
             physicians to population.  According to the 1968 analysis of all
             health indicaters, only one Mississippi county is on equal footing
             with the top half of the nation; 62 of the 82 counties fall into  the
             lowest one-sixth of all counties in the United States in health status.
             Few resources are at hand to correct this deficit. The State  is  62%
             rural. The average per capita income is less than $1,800 per year;
             almost half the families have annual incomes under $3,000.  Of the
             families in the bare subsistence category, about 53% are nonwhite and
             43% are white.  The illiteracy rate is about 5% double the national
             average with an average of less than nine years of schooling reported
             by Mississippi adults.

             REGIONAL DEVELOPMENT
             In November 1965 the Mississippi Heart Association invited representatives
             of health and civic organizations collectively to consider the  potential
             for Mississippi of the newly enacted legislation setting up the  Regional
             Medical Programs. Dr. Robert Q. Marston, then the Vice-Chancellor of  the
             University of Mississippi, Congressman G.V. Montgomery, then President  of
             the Mississippi Heart Association, and Dr. Warren N. Bell, then  President
             of the Mississippi Division of the American Cancer Society, were asked  to
             serve as an ad hoc committee to develop a planning group.  The Mississippi
             Heart Association, the Mississippi Division of the American Cancer Society,
             the University Medical Center, and the State Board of Health each contributed
             $2,000 toward the cost of planning activities. Concurrently,  Dr.  Marston
             Appointed an ad hoc committee categorical study groups to pool their know-
             ledge in heart disease, cancer and stroke as a resource for the overall
             planning group.  In September 1966, Dr. Guy Campbell, Chief of the
             Pulmonary Disease Section at the VA Hospital, was employed as a  half-time
             coordinator for the proposed Mississippi Regional Medical  Program.  From
             November through December 1966, the ad hoc study groups furnished the
             planners a,broad assessment of the level amount, site of pertinent






            MISSISSIPPI RNP                    -7--             RM 00057  5/71


            and competencies.  An 18 member Pc-,.gional Advisory Group was  designated,
            including 8 from Jackson, and 10 from the rest of   the State.  In
            December 1966, the RAG considered an initial draft of the Regional
            planning grant application which was later submitted to DMQ.  After
            a site visit was made and consultation was provided  from  the  Division
            of Regional Medical Programs, the application was revised and resubmitted
            in April- 1967. Funding began for the Mississippi  Regional  Medical  Pro-
            gram on July 1, 1967, with the University of  Mississippi  Medical  Center
            as the fiscal agent.  During the planning period, the Region also
            received funds for two feasibility studies from  earmarked  funds:  to  set
            up a demonstration stroke unit and a training program  in  chronic  pul-
            lwnary diseases. Another project for hypertension control.  in  the  rural
            Delta County was also submitted, but not approved.

            The operational program application was submitted  in  March  1969.  The
            Region was site visited in May 1969 and the Region was awarded operational
            funds on July 1, 1969.


            ORGANIZATION STRUCTURE AND PROCESSES


            The RAG now consists of 36 members, 17 of whom are new members.  The
            geographic representation in the RAG is statewide.  Eight  of  the  members
            can be identified as minority representatives.  The RAG consists of
            representatives of a variety of state organizations including  Compre'rien-
            sive Health Planning, Medicaid, the presidents of the Mississippi College,
            Jackson State College, and Alcorn College, a faculty  member  from  Alcorn,
            the Dean of the School of Nursing from the University of Southern
            Mississippi, the Acting Dean of the Medical Center and the Director of
            the University Hospital.

            The RAG has concentrated this past year in developing a plan o  action
            for the future. Formerly, consumer members on the  RAG  were  not  involved
            in the program and the core staff has made a deliberate attempt to
            increase their commitment through better  orientation.  In  addition,  a
            retreat was held with the RAG staff and the Planning Committee to deveio@
            clear objectives and prior ties.

            The Planning Committee is, and has bee@ a key group in the organization of
            this Regional Medical Program.  Consisting of 15 elected members from the
            Heart, Cancer, Stroke, Continuing Education and Hospital Liaison Committees,
            it represents the peer review structure in the Region.  Eleven  of  the  15
            members are from Jackson, 9 are from the University itself.  Since the
            initial categorical committees were appointed by Dr. Marston, these
            committees have played an important role in  the  Regional  development.

            The review process is under study in an attempt to streamline it.  Briefly,
            the steps now involved are: the idea is developed  by  a  proposer,  the
            coordinator considers it, the categorical  coordinators  provide  consulta-
            tion and help, staff reviews it, a categorical committee  reviews  it  with
            help from paid consultants, if necessary. Then, it  goes  to  the  Planning
            Committee which looks at its relevance to the program and assigns a




            MISSISSIPPI RNP                                   RM 00057  5/71

            priority. Finally, it goes to the RAG which  studies  it  from  the  stand-
            point of relevance to overall goals and priorities of the program.
            The evaluation of the ongoing activities and the program  as  a  whole  is
            also under study, with the Planning Committee  taking  a  major  role.  The
            progress reports from the project directors are studied by staff with
            help from a new consultant in  evaluation.  Any.problem  areas  are  worked
            out by the staff and the categorical committees.  The RAG does not
            appear to have a major role in evaluation at the present time.

            OBJECTIVES AND PRIORITIES

            The objectives most recently defined by the RAG at its workshop     retreat
            in December are as follows:
                  (1) To alleviate the health  manpower  shortage.  (This  has  always
                      been the number one priority for this RMP.)

                  (2) To encourage improved designs for systems for health care
                      delivery in Mississippi.

                  (3) To provide continuing education for the health team.
                  (4) To stimulate public education regarding concepts and resources.
            The priorities to be exercised in meeting  these  objectives  include:  a)
            incorporating minority groups in the health  manpower  pool,  as  possible
            b) to make the health care delivery system receptive to the Region's
            necessitous citizens; c) to shift the focus  of  emphasis  to  responsible
            action on the local community while still maintaining  regional  trainir,,,
            and consultation services as resources for  local  health  care  providers;
            d) to reach the functionally illiterate and stimulate an informed interest
            in health matters; and e) to encourage emphasis on quality, equity,
            efficiency, and economy in the delivery of health care.

            PRESENT APPLICATION_
            Developmental Component                              First Year -  $97,518
            The Region requests $97,518 for one year for the Developmental Component.
            The plans are to use developmental funds for  the  following  purposes:  1)
            initiate support for relevant activity when  delay  would  be  detrimental
            to optimal impact; 2) to deal with unforeseen problems in program
            implementation; 3) to enhance the effectiveness  of  ongoing  projects  by
            filling the gap between them; 4) to take advantage of special skills,
            personnel or opportunities if they become  available;  5)  to  participate
            in appropriate federally-supported and other programs as they become
            available; 6) to test the feasibility of new program activity or concepts
           .by the use of the  small-scale  pilot  projects.  Devel-opmental'component
            funds are conceived as a tool to grasp  unique  opportunities  not  subject
            to nor bound by technical restrictions applicable  to  formal.  operational





            MISSISSIPPI RMP                   -9-                  RM 00057  5/71

            projects. They will not be used to e-f-.Iarge OY  extend  the  core  staff.
            Any proposed activity must be consistent with the objectives and
            priorities and there must be a substantial- probability that the
            activity will  produce  information  applicable  to  future  programmatic
            decisions.

            The application further  states  that  the  proposed  developmental  activity
            should be capable of activation with minimal  delay,  it  @;hould  have  an
            action component, and it should be capable of generating much more
            volu,                involvement and participation than could be purchased
                 iteer interest,
            on a total cost  basis.  The  administrative  procedures  for  allocation  of
            developmental component funds will be  initiated  by  the  Plannin@  Coni-
            mittee and approved by the RAG.  The core staff will play an important
            role in perceiving opportunities  and  receiving  requests  for  the  most
            appropriate use of such funds and  will  provide  the  Planning  Coumiittee
            and the RAG with  information,  research  and  developmental  services  for
            their study. The RAG  will  have  a  developmental  component  study  group
            for preliminary review of the developmental component proposals to enable
            the RAG prior study of the potential by their own group.

            Core Activities                                  Third  Year  -  $362,957

            Dr. T. D. Lampton, who came to the Mississippi  Regional  P4edi-cal  PrograTr
            as Heart, Stroke Coordinator in July  19(@8,  became  the  Coordinator  in
            January. The Staff has also been  strengthened  by  the  addition  of  Ili
            individual experienced and trained in personnel practices, Pat L.
            Gilliland, named Assistant  Director  for  Program  Coordination  in  January.
            At the beginning of this current year,  the  core  staff  numbered  11  full-
            time and six part-time personnel in all categories.  Two medical stu ents
            were also  employed  during  the  summer.  Six  budgeted professional   and
            technical  positions  were  unfilled.  In  January,  the staff totaled  22  at
            all levels,  15  full-time  and  seven  part-time.  Only two  budgeted  pro-
            fessional and technical  slots  are  now  open.  Of  the six  professional  and
            technical staff who are  less  than  full-time,  one  is shared  with  the
            stroke unit, one is a Jackson physician, one is self-emp.'Loyed and  thr(-@,@
            are shared with the University Medical Center.  The RAG indicates they
            like the trend toward full-time staff.

            Analysis of the total core  staff  activities  in  the  application  indicates
            that most effort is directed toward:  (a)  project  development  and  manage--
            me-nt and (b) professional  consultation  and  community  re'Lations,each
            accounting for some 25% of the total.  About 15% each goes to: (c)
            program administration and direction  and  (d)  planning  studies  and  inven-
            tories. While  (e)  feasibility  studies  and  (f)  miscellaneous  activities
            are estimated to absorb 10% each  of  the  total  effort.  Work  with  com-
            munity, sub-regional and regional groups in development of cooperative
            arrangements will command grea'@er porportions  of  staff  effort  In  the
            coming year. By RAG direction,  the  fiel.d  services  will  be  expanded
            with the two field workers designated, for this act@l.vity.
            The application indicates that the core staff  has  rel.ated  to  a  number
            of different agencies within  the  state.  For  examples  the  core  staff




                                                -iO-                    RM  00057   5/71
              MISSISSIPPI RMP
              helped a local medical society centralize its health and welfare
              information service. It helped a group  called  "Operation  Shoe  String,'
              a local non-profit organization which provides a  variety  of  services  in
              a transitional poor neighborhood seek new  sources  of  funds.  The  State
              Medical Association is exploring with the core  staff  the  possibility  of
              developing a utilization and review manual for primary use with peer
              review committee functions through the medical association.  The
              Mississippi Dietetic Association is  requesting  help  with  the  develop-
              ment of a dietetic manual training program  for  food  service  supervisors
              in continuing education workshops for  dieticians.  A  number  of  planning
              and feasibility studies are described  in  the  application.  The  core
              staff has served as consultants for several joint efforts, including
              the health law compilation with Comprehensive Health Planning, a
              hospital management study with  the  Mississippi  Hospital  Association
              and the Mississippi State University, and a  survey  of  Lafayette  County
              health needs with the Memphis  Regional  Medical  Program.  The  University
              of Mississippi, the Mississippi State  University,  the  University  of
              Southern Mississippi, the Mississippi  Research  and  Development  Center,
              and core are cooperating in conducting  studies  in  manpower  development.
              Hines Junior College helped to  structure  clinical  training  aspects  of
              three RMP established training programs  for  allied  health  professions.
              A general impression from the core progress report  is  that  the  limited
              resources in Mississippi contribute to cooperation among the various
              professional  staffs.  Vocational  Rehabilitation,  Comprehensive   Health
              Planning, the State Board of Health,  universities  and  other  educational
              institutions are involved in PM .  The core staff has also been
              instrumental in developing a grant application to the Appalachian
              Regional Commission for a 20 county area.  In addition, the staff      has
              been involved in developing a maternal  and  child  health  program  aimed
              at reducing maternal and infant deaths in  a  rural  five-county  area,
              funded from five different sources.
              ONGOING OPERATIONAL ACTIVITIES                  Third Year  -  $603,203
              A study bf elected funding characteristics of   the operational activities
              supported by the Mississippi Regional Medical   Program  contrasted   with
              funding characteristics of all Regional  Medical  Program  projects  points
              out a revealing profile for Mississippi.

                                                    mi                  All     ons


              Sponsoring Agency
                Medical School                          77%                  41%
                Public health agencies                  16%                   5%

              Training for Health Professions
                Separate programs for MD's,
                  RN's or MP's and RN's                 23%                  47%
                Other combination, including
                  Allied Health, LPN'S, etc.            77%                  35%



             MISSISSIPPI RMP                                      Rm  00057  5/71


                                                      lissil            All Region
                                                            S


             Activities Toward Target Populations
              Poor                                        43%               15%
              Not applicable                              57%               85%

             Categorical Impact
              Heart                                       28%               24%
              Cancer                                       7%               12%
              Stroke                                      29%               13%
              Pulmonary                                   27%                  7%
              Multicategorical                             9%               38%

             Health Care Impact
              Diagnosis & Therapeutic                     73%               34%
             The tie-in of the leading institutions and   the combination of training
             and consultation service to  target  populations indicate that  this
             Region is reaching an impressive number of communities and patients
             not previously served.
             For example, the stroke unit not only provides  care  to  patients  that
             was simply unavailable before, the @ staff provides consultation
             to physicians and patients through a neurology project and cardio-
             vascular clinics planned by the State  Board  of  Health.  The  Coronary
             Cate Training project involves the University  Medical  Center,  the  VA
             Hospital as clinical training centers; in  the  first  course,  eight  nurses
             from five communities, in the second - 15  nurses  from  6  communities,  and
             in the third - 11 from 7 communities have been trained.  The radiation
             therapy project serves 51 new patients a month, compared with about 36
             before the RMP support began.  Family physicians have been trained,
             radiologists have been provided regular dosir,,ietry service at  the  VA
             Hospital, Mississippi Baptist Hospital,  and  the  Howard  Memorial  Hospital
             at Biloxi. The radiation  therapist  has  provided  consultation  to
             physicians in eight different communities.  The radiation physicist
             has provided-help to nine  hospitals  in  seven  communities.  New  treatment
             centers at Oxford, Tupelo and Meridian, Mississippi are being established.
             Forty-two neurology clinics in 14 different locations have provided
             consultation and patient service.Through the social worker at the Univer-
             sity, patients have received referralservice to welfare, Crippled
             Childrenis Society, Vocational  Rehabilitation,  Mental  Health  and  special
             education courses,.  The CPR project sponsored by the Heart Association
             has held 220 courses; 66 hospitals are participating.  Faculty instructors
             have been increased from about 20 to 139.  Seventy-eight hospitals now
             have CPR committees and 37 have code-blue procedures.
             NEW OPERATIONAL PROPOSALS                                            First  ear
                                                                                       C'St
             #16 - Statewide Community Stroke Rehabilitation Program                $42,505
                   This is a pr posal sponsored by the Mississippi Heart
             Association to plan the development of model stroke centers




              MISSISSIPPI RMP                       -12-              RM  00057   5/71
              in each of the health care sheds of Mississippi, to serve the
              diagnostic, treatment  and  rehabilitation  needs  of  patients  in  the
              surrounding areas. Funds are  now  requested  only  for  Phase  I  of  the
              project to concentrate on  developing  a  prcitocol  for  optimum  care
              of stroke patients, to recruit volunteer physicians, nurses and
              physical therapists f  or  team  training  at  the  @  Stroke  Unit  as
              a.prelude to the organization of the community stroke centers.
              During Phase I,  community  interest  and  involvement  will  be  enlisted
              to aid in the development of the stroke units.
              The CPR training plan will be used  as  the  model  for  the  project  with
              its  "each-one-teach-one"  approach  and  community  involvement  as  focal
              points. The  proposal  speaks  of  the  neurology  clinics  now  operating
              with      funding, but  its  relation  and  comparative  priority  for  the
              Regional Medical  Program  is  not  clearly  stated.  Three  additional
              years of funding are  anticipated  for  Phase.II  of  the  project,  but
              the funding needs are not projected at this time.  The Region anticipates
              putting in a request for the next  three  years  at  the  time  of  its
              triennium application.
              #17 - Renal Disease Progr@      A version  of  this  proposal  was     First Year
                    included in the initial operational application from             Request
              the NRNP.  The site visit team learned that a chronic Hemo-             $200,739
              dialysis Demonstration  Program  had  been  supported  since  1966
              and would receive  partial  support  through  1970  through  other
              Federal funds.  (Kidney  Disease  Control  Program,  now  part  of
              RMPS has been instrumental in this support.)  The site visitors
              recommendations,  supported  subsequently  by  Committee  and   Council,
              were to provide partial  RMP  support  for  further  planning  and
              development of the training aspects of the program.  The July 1970
              Advisory Council reviewed  a  revision  of  the  original  proposal  and
              returned it for revision.  The recommendation stated that the
              '@eturned for revisio-d'was not to  be  construed  as  encouragement  to
              submit a revision, that  the  concerns  were  related  to  the  relation
              and expense of this  activity  as  compared  to  other  health  priorities
                'the RMP.  This particular proposal has been developed with
              in
              assistance from the  Kidney  Disease  Program  Staff.  To  keep  the  unit
              viable during the time  that  the  revised  program  was  being  developed,
              the Director, under the delegated authority, allowed the Region to
              utilize $47,347 in direct costs funds from carryover.
              This proposal thus represents a  third  attempt  by  the  RMP  to  achieve
              stable support for its  renal  program  during  a  period  when  Federal
              guidelines and  priorities  have  been  shifting.  The  proposal  will  be
              reviewed for its  technical  merits  in  relation  to  national  guidelines
              by an ad hoc renal panel.
              The proposal is divided into three parts:
                   1.  Comprehensive Renal Training Program
                  II.  Decentralized Home Dialysis Centers
                 III.  Urinary Catheter Care





           MISSISSIPPI RNP                                    RM 00057  5/71

           Earlier reviews pointed to the necessity for the  Mississippi  Regional
           Medical Program'to plan its program focus in relation  to  resources
           available in nearby states, as well as within its own state.  A
           unique feature of the earlier proposals cited by the  reviewers,  was
           related to the trailer dialysis training in communities.

           The present proposal includes several trainee features which  may  be
           contrary to Council policy.

           02 Year - $184,143                    03   $190,354

           #18 - Hypertension Control Demonstration    This Region submitted     First Year
                 a hypertension screening application for earmarked funds         Request
           during its planning period.  The proposal. was located in               $70,790
           Bolivar County and was disapproved, primarily because of  its
           isolated development and apparent lack of commitment by the
           practicing physicians serving in the area.
           The present project proposes to screen the population of Sharkey
           and Issaquena counties, two of the most rural,  sparsely  populated,
           low income counties in Mississippi in "an effort to determine the
           incidence of hypertension."  Diagnosis, treatment and fol.low-up
           of hypertensive patients will be provided by the  health  department,
           the sponsoring agency, with assistance from the local medical
           personnel and the University Medical Center. A  letter  of  agreement
           to serve as co-sponsor is included from one of the local physicians.
           Aside from the objective of determining the feasibility  of  screening,
           the project's objectives include: 1) Demonstrating the ability of
           nursing and allied health personnel to conduct a  screening  program
           with minimum physician supervision; 2) Demonstrating  that  education
           about hypertension will increase knowledge of the public so  they  will
           seek care.

           Initial screening will focus on "target" groups such as public
           recipients, especially the disabledand old  age  recipients.  Bi-monthly
           diagnostic and evaluation clinics will be held utilizing  staff  and
           residents from the University Medical Center.
           A screenee may elect to receive care from a private physician or the
           clinics mentioned above. Social service  technicians  will  follow-up
           the private patients. For those utilizing  clinic  services,  laboratory
           and drugs will be provided as needed.  Mississippi's  minimum  medicaid
           benefits presage a large number of patients requiring  drug  therapy
           support through this project. There are no plans for  phasing  out  this
           aspect of the program.
           02 - $74,410                                    03 - $77,515




             NISSISSIPPI RNP                    -14-              RM@@00057  5/71

             #8R - Cardiopulmonary Resuscitation Training - This is a              Th-ird Year
                   request for three additional years for the Cardio-               Request
             pulmonary  Resuscitation  Training.  When  the  site  visit  team      $53,267
             visited the Region  in  its  pre-operational  phase,  they  found
             that this project was  very  important  but  recommended  that  the
             project be supported for  two  years  only  and  be  non-renewable.
             Since the project began, a number of training courses have been
             held and 66  hospitals  are  participating.  The  next  three  years
             of the project indicate that they  will  extend  to  all  of  the
             hospitals instruction for  the  hospital  teams  and  in  addition,
             the application states "there is  a  great  need  for  training  in ECPR
             to be made available to all ambulance personnel, rescue squads,
             civil defense,  fire  and  police  departments,  Highway  Patrol,
             National Guard, utility  companies  and  employees  of  their  high
             risk industries, life  guards,  school  officials,  Boy  Scouts  and
             community groups or organizations." This aspect of the training
             program is  contrary  to  Council  guidelines,  which-indicate  that
             RNP support for CPR  training  activity  should  be  confined  to
             hospital-related  personnel,  including  ambulance   drivers.   The
             proposal for the next three years does not speak to any specifics.

             04   $42,470                              05   $33,320






















                                                          RMPS/GRB
                                                          3/24/71








                                      ST.WIARY OF REVIEW AND       COI@CLUSION    OF
                                           APRIL 1971 REVIE@,L     CO@ELMITTEE


                                     llvLSSISS'@LPPI REG@LONAL 'r  D  ATCAL  PROGRAM
                                                   RM 00057  5/71@

                                FOR COt4S!DERAtIO@N BY MAY 1971 ADVISORY COUI@ICIL



               RECO@lf,@,T,'Nl,i'kTION.- Approval  at  the   current   level   with   advice   not   to   fund
                                     renewal of the CPR project.   The recommendation does
               not  include   consideration   of   the   renal   disease   project   #1.7   which   was
               reviewed simultaneously by a special R@IPS Ad Hoc Study Panel.  The
               panel  recommended   its   approval   with   a   site   visit   to   negotiate   a   reduced
               budget.

               Support requested by the Region and recommended by the Reviet,7 Committee:

                                                           --.Direct Costs

                     f)@r@tionzil Y acquire                Re      tee,            Recommended

                                 03                        $1,430,979              $1.,095,428

                                 04                             301.,023               141,623---

                                 05                            301   l@9                  -O---

                                  TOTAL                    $2,033,191              $1,237,051

                 P,14PS commitment for support of the stroke           project   in   its   third    year.


               CRITIOUF,-  The  Review  Committee   noted   that   the   IfRt@IP   is   currently   in
                             its   2nd   operational   year   funded   at   $1,   095,428.   The   Region's
               first   triennial,   application   under   the   new    anniversary    review    system,
               is expected at this same time next year, when a site visit will be
               conducted.   MeenTYhile   the   Region   optioiied-,.to    request    a    developmental
               component  and  support   for   new   projects   as   part   of   planning   that   has
               dc@vel.6ped   this   yeer.

               The    former    associate coordinator   i-I   no,,7   full-time    Coordinator.    His
               predecessor       resigned to worli: -'Ll.111 time for the VA., bit remains on the
               RAG.  A  change  in  the   Dcan   of   the   Univorbity   is   al,ro   noted.   Of   special
               interest to Corr,.iiittf',c-, x.@@n:,re points  raised  by  staff  cm  review  of,  the
               conti.,noa,L- iorL api)l-j-CaLicti-t. Al.thoLigb the l@iG  has  taken  on  a  new  mevAber,
               and seems more active iii develol.,irig I)rogriTa direction and priorities;
               they  have  not  tal,,en  positive   ,steps   to   phase   out   some   current   activities
               and move It-,i new directions.                      of  th-k.s  is  their  request   for
               r nr--i,7al of the CIII', project         has  rece-)@.vcd  support  for   t@7o   years,
                            recorl'i,,iicnded by the l@4ay 1969 -,Ite               Althotioh      manage-
               t'r e I i!n ii- t                                                            c@
               mf,-,nt techniques hL-ve  not  been  fully  dz,--v,@@iop,,,2(i,  a  fairly  effective  core
               staff b@-@s CVO'J.17C-(J' and is
               developing with Appropriate statewide                                 in the state






              MISSISSIPPI Rll@@                       -2-                          RM 00057  5/71


              and there is or, eciii@hasiE,, on @,uo-area  development.  iTealth  m,,inpo-v7er
              continues to be ti-@c,             top  priority  and  success  has   been   atliieved
              in generating tJni.vcri@l.t.@r @i,-clical Center assistance  to  all.  parts  of  the
              state,  as  well  as  involving  ot'Ller  institutions   of   higher   learning.
              In light of the findings  citir:Litg.  pnst:  site  visitF,,  the  Committee  is  well
              aware of  the  dearth  of  hcaJ.tl,-i  care  needs  of  Mississippi  and  the  fact
              that  it  has  only  one  medical  @-cliool,center  located  at  Jacl,,son,   For
              this  reason,  as  has  been  the  case  in  previous  reviews,   t   e   Committee
              was  concerned  about  the   type   of   activities-presented   for   support   with
              the limited available funds.  In general, it is bel.ieved that the
              activities proposed are  not  ne,17  nor  do  they  relate  i-7el.1  with  the  stated
              objectives  and  priorities.   Projects   i@;ith   continuation   com@ll-itments
              probably merit continued suvdl?ort but the region  slioLil.,]  bcairt  no-,,?  to
              pl-6n  for  appropriate  phasing  out  RI@FP  support.  Al.though  the   Rcaioii
              needs some funds for                    sorr..l-@ nex-Y and
              approval  of  a  dcvelopr@icnt,31  component  at  this  time-,  is  premature.   The
              proposed  new  project  on  strole  rehabilitation   rel@iter;   to   the   ongoing
              stroke -care project 1"'I,R which is sl.ated for one more year of RIIP support,
              The  hypertension  project  does  not  relate   to   the   coronary   care   project
              and it is believed that it -v7ill@ not provide epidemological data expected.
              The  Committee  also  expressed   concern   about   continuation   of   the   latter
              after cessation of M,,T support.  The Committee believed the renal
              disease project has merit but is concerned about the Rcgion's hesitation
              to  invest  its  funds  in  more  basic  problem   areas   affecting   more   people.
              Some  though  that  unless  the  Region  has   the   capacity   -.nd/or   resources,
              despite  the  renal.  program's   excellence,   it   might   impede   t@te-function
              of the Region in general.

              In  general.,  the  Committee  believed   Mississippi   is   making   some   progress,
              but  has  awesome  problems  and  limited   resources.   RAG   and   Core   have
              not   yet   developed   sufficient   management   and   evaluation   capabilities
              to  warrant  full  support.  The   Committee   bel.icved   that   merely   taking
              this action and sending back the i.,igrd is not enough,  Direct RLMPS
              assistance  is  needed  in  llississippi  prior'-to   their-sttbmissi.on   of   the
              next  application.  This  might  be  accomplished  best  by   a   "thitilr,   session"
              with Rii@S participation and/or a pre-site visit.
                          I
              RI@IPS AD ll.OC KIDNEY DISEASE C Ll'f    P,-  The  panel  thought  this  to  be   an,
                                                            excellent proposal, well documented,
              and describing on area of the country         in  Deed  of   assistance.   It   was,
              however,  believed  that  the  budget  should   be   reduccd'frotti   $270,048   to
              a  range  of  $75,000-$100,000.  The   Panel.   recommended   approval   with   a
              site visit to negotiate a reduced budget.







                                                                                CPB/Rl@iPS/4/26/71.







                                       MISSOURI S     Y


                                      TABLE OF CONTENTS



                                                                     Page No.

               General                                                   1

               Fiscal Information                                        2

               Geography and Demography                                  6
               Orgatizational Structure  and Processes                   6

               Regional Development                                      7
                   Planning                                              7
                   Operational Program                                   7
                     Early Background                                    7
                     computer and Bioengineering Program                 8
                     community-Based Programs, including                 9
                       Kansas City
                     Continuing Education Program                      11

               Regional Objectives                                     11
               Application                                             13
                   Developmental Component                             13
                   Core                                                14
                   Computer/Bioengineering  Proposals                  16
                   Comunity-Based Proposals                            18
                   Continuing Education Proposals                      22









                                                       (A Privileged Communication)




                               REGIONAL MEDICAL PROGRAMS SERVICE
                    S     Y OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION




             Missouri Regional Medical Program           RM 00009-05  5/71
             406 Turner Avenue - Lewis Hall              April 1971 Review  Committee
             Columbia, Missouri,  65201


             Program Coordinator:  Arthur E. Rikli, M.D., M.P.H.


             This Region is currently funded at $3,800,000 (direct costs) for its
             fourth operational year (ending June 30, 1971.  It submits a triennium
             application that requests:

                   1. A Developmental Component
                  II. An expanded core
                 III. The continuation of 11 ongoing activities
                  IV. The renewal of two activities
                   V. The activation of two Council approved but unfunded  activities
                  VI. The implementation  of 16 new activities
                 VII. The termination of 15 activities

             The Region requests $5,061,962 for its fifth year of operation, $4,310,940
             for its sixth year and $3,511,564 for its seventh year.  A breakout chart
             identifying the components for each of the three years follows.

             Several of the proposed new activities have previous review histories,
             which will be elaborated on later in the body of this summary.

             A site visit is planned for this Region, and staff's preliminary  review
             of the application has identified several issues for the site visit
             team's consideration.


             Because of the complex nature of the Missouri program, the site visit has
             been divided into four parts dealing with:  1) the review, decision-making
             and administrative processes of the overall program (to be reviewed in
             Columbia, Missouri); 2) the continuing education program (Columbia);  3)
             the computer and bioengineering activities (Salem and Columbia); and  4)
             the development of the subregional program  in Kansas City.   The issues
             related to each of these components are discussed in detail in the  sum-
             mary and in a separate memo to the site visitors.




             MISSOURI RMP                        -2-                   RM 00009'05


                                         FUNDING HISTORY


                                         Planning Stage

             Grant Year                       Period                  Funded
               01                               -  6/30/67          $  332,130
               02                        7/l/67  -3/31/68             255,93

                                         Operation Program
               01                        4/l/67 - 3/31/68           2,619,000
               02                        4/l/68 - 3/31/69           4,681,609 1
               03                        4/l/69 - 6/30/70           5,678,568 f/ & 2/
               04                        7/l/70 - 6/30/71           3,800,000
               05  Future  Commitment  for  Core and 6 Projects     1,851,610
               06  Future  Commitment  for  Core and 5 Projects     1,707,075


             1/  Includes A restriction of $240,343, which was placed in the 02 year,
                 carried over to the 03 and never released to the Region.

             2/  For  a  15-month  period.










                                                                                                                                                   L

                                                                                                                                                                          RER,!DN               t4lSSOURI
                                                                                                                                                                          CYCLE          RM        000()q  5     /71
                                                                                         BREAKOUT  OV  REQT.TEST                       05                  PERIOD                         Trienniut,)


                                                                                                                                                     NEV
                                                                                                                                        -9              !ACT!',IIT:LES    i DIIZECT            IINDIRECT                 TOTAL
                                                                              AG-EIVITI.ES          iltE,@L@4AL                  iAPPR/UN
                       '@DEVrLOPMF.NTAL COMPONENT                                                                                               :$     400,0()O           I$    400,000             -n-                  400,0(10
                                                                                                                                                                                                    156-!
                       'CorlE                                                 $1   474,165                                                                                ._I,474.165                          _U-_!         1,819,953
                                               ri    ---                      I                                                                                           1     163.419               53.115 @;'         216,654
                                                                              i    161,419
                       @#5n     -     Strokt,     Prpv.      &      Rehnb,                                                                                                         -7@6.
                                                                                   107,796                                                                                      107.796               2Er..       65     136.0(
                       #52        Health  Caree-s                     Program!,    100,777                                                                                      I  00.  7   77_' 2@6        !     f)     126,997@
                                                                                   114,572                                                                                      114,572               15,,iSO            130.452
                                  -C-A- -@'-E -O-,
                       #58        CV  Eetic.  & E%@al.                             116,570                                                                                      116,579               11,167'            149@332
                                                                                                                                                                                   82,566             13,180               95,946
                                                                                           82,566
                       #37        Radioisotope  Program                            102,444                                                                                      102.444                 6,768@           109.212
                                           ii e a 1 t !I A i @.  e  P  o@i         1        1,683                                                                               141,683               45,794             187,1,77
                       el!9       Phoncerdioscan                                          37,21.8                                                                                  17,218      1        7,      -)OO  _45,    11     8
                                                                                                                                                                                   75          8@74----                             83
                       .F4)-=b-FaF t@pi-Tn-cTi'l I dren                                    759874                                                                                                     3@,709             111,5
                       @,162  -  Drug  Infor.  Center                                                                               $32,589                                        32,589             11,870               44,459
                                                                                                                                        4                                          46,R!4             11,794               59,628
                                                                                                                                    46,83
                       1;25R  -  StrOL-e  ICU                                                                                                                                      6,964              9@."72             298,936
                                                                                                                                                                                               i        6,322              37,4nl
                                                       in      Can.       HosO.                                                                          11,079                    @1,079
                                                                                                                                                                   148    i        67     148         'A7        L87
                       @,168     -     Prev.     of     CV     Pultn.     Prob.                                                                  !-_@7                                                             -     104.615
                                                                                                                                                       290.710            i     29n,710               51   ,    n6-7     ?41.777
                                                   Tia,-  Airiq                                                                                                           i        58,40.5            14,161               /Z,  -)  72
                       1726.R-     Nurse     Trng7Arrhy.      &      Reg      i                           58  405
                                                                                                                                                         75,07n                    75,070             1   2,   @161,1      Q7.4'1,4
                       #71     -  APHAS  Firld  Tp-tt
                       417     -  ALTD,  Ph,,-t.                                                                                                              5  1   7                                                   171       q"g
                                                                                                                                                                                                      in
                       #71     -      Sub-Retz.       E-,nprg.       Serv,                                                                               ',9,883                   18.888                       @168       40,    r)56
                                                                                                                                                                                   7@A77                           1,              pni
                               --Z@e_i_-z
                                                                                                                                                       142,6?P                  i42,428               74,114             417,142
                       ,#75    -     Bio,-.erlical      Tnfo.      Sfrv.      j
                               -      lxnl,,ilp       Rpbar-       Re-vice                                                                  --O_l                 27(,             91@776                   'I')   7     I I PI (In '4
                                                                                                                                                                14,651          184,651               16.      1,Fll     221,112
                       4T 7 7  -  Ca-,;iar  Care                                                                                                                          I
                                                                                                                                                                                   91     44n         ii-sn?

                       @7q     -  l@-ovement  of

                                                                                                                                                         11.9ni                    11,901                       56,9       12.670
                       #PI        CaTpron  Health  Care

                                                                                                                                                                                                                         145,@78
                                  CE  -  Coordination                                                                                                  114.062                  114,062               @1,116
                                  G-repn                lits-I @h @@r                                                                                                              9 'i - 6 61
                       070        Unassigned
                                                                                                                                                                                               @@,146,117
                                                                                                                                    $79,423       @$2,tl2p
                                                                               $7,6n4,737             $,7@)5,369                                                   433    $5,O6lt962                               $6,    2()8,    079











                                                                                                                                                                          REGIO
                                                                                                                                                                          CYCL7
                                                                                                                                                                                  Triennium@
                                                                                   BRE,@KOUT  OF REQUEST                    06                       -PERIOD


                          T       c  T i      0                               CO',@TI"Ul',\G    I                   ;PRIZVICTJSL'!                !iEW
                                                                                                                                                                                         T,\IDIRE@@T              TOTAL
                                                                                                                                                  IT.;ACTIVITIES     DIRECT
                                                                          AC',-                                                  'Pt!,      .
                                                                              IVITES            ;RENEWAL            JAPPr,/UN
                                                                                                I                   ;    .                                                    on,ono
                                                                                                                                            I$           400,000   i$    4
                        DE'v'ELOP@INTAL
                                                                              r)27.
                        COPE                                                                                                                                         i-,687,83
                                                                              179,458                                                                                    179,458
                                                                                r          7                                                                                  63
                                                                                                                                                                                     .,157
                                                                                P,5,214                                                                                                 14
                                                                                                                                                                                        45
                                                                              119,11@5
                                                                                                                                                                         126,111         i
                                                                              120,5]i                                                                                    120,511
                        .K, r
                          3 7


                                                                                                                                                                              81,986     i
                                                                                81,98
                                                                                           6    i
                                                                                                                                                                              36,984
                                                                                                                        $36.984             i
                                                                                                                       --                                             -4T              708
                                                                                                                                                                              52,272
                                                                                                  $52    2 72
                         @25R
                                                                                                                                                     IS3,  83  6   I
                                                                                                                                                                              7,095
                                                                                                                                                     67,095                   6
                           6 3
                                                                                                                                                                                         -2:1
                                                                                                                                                             822              17e,82
                                                                                                    52,364
                          !72 6R                                                                                                                                              52.364


                          #73
                                                                                                                                            i        37,595         1         37,
                          @;74                                                                                                                                                288,/4/4n
                                                                                                                                                     2SR.440
                              6                                                                                                                      94,f,25                  94,625
                                                                                                                                                     15().554                 159,554
                            7 7
                                                                                                                                            i        47,480                   47.
                            7                                                                                                                                                          480
                                                                                                                                                     71,610                   73,610     i
                                                                                                                                                     In,146?                  10.461
                                                                                                                                                             460              28,460
                                                                                                                                                     2 ,R.
                                                                                                                                                                              142      94n
                                                                                                                                                     142,940
                                                                                                                                                     95.077                   95.077
                            0   -  Unassigned

                                                                                                1$10,'@,636              $84,692                                    -'$4,   31   0,    940
                                                     T 0 Ttt'-                    $2,463,615                                                          $I,657,997










                                                                                                                                                                                                           Rm oooog   5171




                                                                                                 BR:-:AKOL'T OF REQUEST    07                      PERIOD



                                                                                                                                                                                                    ALL Y-LARS           ALT- Y-ZARS
                                                                                                                           A
                                                                                                                              N:-: w
                                           :T       ACT!'                                                                  CTTV'4'T_'-           DIRECT         114T
                                                                                              APPR. /U'@FTq.                                                        )I@EC           TOTAL           DiRzLCT
                                                                                                                     f$   40r),   Onr)           400                                             is      i,?nn.or)o
                                   "OP.                                                                                                                 nnr)
                                                             6, 61 7                                                 F-                          8() 6.  1   7
                                                                                                                                                                                                           lt2.1'771


                                 2                        ---                                                                                                                                                       322!
                                 5                                                                                                                                                                         240,681!
                                                                                           I                                                                                                               247,081
                                                                                                                                                                                                           -82.56@
                                 7
                                                                                                                                                                                                             _102.41-4
                            iL
                                                                                                                                                                                                           141,68-.
                                                                                                                                                                                                           17,218
                                                                                                                                                                                                           157,860
                            @62                                                                  $39,165             1                             19   1 6 -5                                  i          108,738     i                             VI
                            #;;4                                                                  50,259             1                             50,259                                                  144,801     1
                            @,2 5R                                                                                                                                                                         259,236
                                                                                                                              45.085               45,085                                                  110,000
                                                                                                                                                                                                           1-34,24-3
                                 "9                                                                                        12Z,716                 22,71(,
                                                                                                                                                                                                           592,24,R
                            #26R                                            $52,287
                                                                                                                                                   52,2871                                                 63,056
                                                                                                                                                   ---                                                     75,070

                                 7 2

                            @,74                                                                                                                                                                           85@222
                                 75                                                                                        259,440               2 ',9                rn
                                                                                                                                                         44f,)                                             890, @r,,s
                            ii   r
                                                                                                                           153      82@@         f53,82
                            1;77                                                                                                  L                                                                        498,027
                                 -7                                                                                           47,778      -        47.778                      i                           148.6QS
                                 8
                                 7c)                                                                                          7'4 @ 61 f,)         71,r,10                                                 221,21n     1
                                                                                                                                  463              10     4@,'
                                                                                                                              I 0-1                                                                        32.  @,7  7
                                                                                                                                                    g,   o.()o
                                                                                                                                                                                                           76,L25
                                 2                                                                                         250.2115              256@2!15                                                  9    P@ 4 7
                                                                                                                                  tl77-'           9 5,     77                                             2t'15 81   5
                                            ssigned
                                                 1 $1,896,617                $52,287                    1,24         $1,473,236

                                                                                                                                                                                                                       'GRB
                                                                                                                                                                                                                               3/l/71







           Missouri Regional Medical Program      -6-                  RM 00009 5/71

           GEOGRAPHY AND DEMOGRAPHY  The Missouri RMP boundary is roughly that of
                                       the Statels, except for forty-two counties
           in the St. Louis area.  The population of 2,849,594 occupies a land
           area of 69,138 square miles.  The Region is 58% urban and roughly
           93% white.

           The Missouri RNP has established  some  relationships  with  the  neighboring
           RMP's of Kansas, Bi@State, Iowa, Oklahoma, Arkansas and Memphis.
           Coordination of MRMP and KRMP activities in Kansas City is effected
           through A,CHP b Council in Kansas City.  A working relationship has      also
           been established with the Memphis RMP in southeast Missouri.

           The MW includes two medical schools and two colleges of osteopathy:
           the University of Missouri Medical School  in  Columbia  with  an  enrollment
           of 412, the University of Missouri Medical School in Kansas City with
           a projected enrollment for its first class (Fall 1971) of 36, the
           Kirksville College of Osteopathy and the  Kansas  City  College  of  Osteopathy.

           The Region has 18 schools of nursing--four baccalaureate, six associate
           degree and eight diploma schools.  There are also 13 medical technical
           schools including .11 baccalaureate and two diploma programs.

           General hospitals (including osteopathic institutions) total 130 with
           15,012 beds.  There are also two Veterans Administration Hospitals with
           728 beds. (The figures for all hospitals exclude extended-care facility
           beds).

           Missouri is served by 2,414 practicing physicians (there are a total of
           2,571 in the Region); 90i active doctors of osteopathy (total 959);
           5,678 active RN's (total 8,518); 4,082 active LPN's (total 5,233); and
           a total of 31,864 other allied health personnel.

           ORGANIZATIONAL STRUCTURE AND  PROCESSES  The  Missouri  RMP  "Regional  Advisory
                                                     Group" is  a  three-part  organization
           composed of a Regional Advisory Council, a Project Review Committee, and a
           Liaison Committee.  The RAG as a whole is designed to establish overall
           policy and to review project proposals.

           The RAC has 12 members appointed by the  Governor  from  candiate.9  recommended
           by the  Project  Review  Committee.  Rob'ert E. Frank, Director of Barnes
           Hospital in St. Louis, has moved from membership on the RAG to the chair-
           manship, replacing retiring  chairman,  Nathan  Stark.  Other  members  include:
           5 practicing physicians, I osteopath, I sociologist (Black), 1 State Senator,
           I State Representative, I attorney and 1 businessman.

           The RAC provides overall guidance on policy, program planning, development
           and operation of MRMP.  Based on recommendations and priorities of the
           other two RAG components and the local District Liaison Committees, the
           RAG sets its own priorities on projects  and  makes  recommendations  to  the
           National Advisory Council.





             Missouri Regional Medical Program       -7-                   RM 00009 5/71
             The Project Review Committee has nine members who represent the four
             medical and osteopathic schools, and the directors of the Missouri
             divisions of Health, Mental Health and Welfare.  This Committee assesses
             project proposals and other,policy matters on merit, establishes  priority
             ratings and forwards these with its recommendations to the RATC.  It also
             recommends candidates to the Governor for RAC membership.
             The Liaison Committee consists of representatives from 23 voluntary and
             professional health agencies. This Committee provides  recommendations  to
             the RAIC on project value and their relevance to the represented agencies,
             besides serving as a two-way communi cations link between agencies and  the
             MRMP.
             In addition to the three RAG components, there are District Liaison
             Committees presently in three of the six      areas - Kansas City,  South-
             west and Southeast, and similar committees are being planned for the ot er

             areas.
             Each committee is responsible for providing recommendations regarding
             lodal need for projects proposed from its own district and impact on other
             areas, as well as for developing its own district policy. The Greater@,
             Kansas City Liaison Committee has been replaced by a group nominated by
             the local CHP "B" agency--an arrangement also being considered by other
             districts.

             REGIONAL DEVELOPMENT
             I.  Planning - Planning began in Missouri in April 1966 with the submission
             of a planning grant application by the Program Coordinator, Dr. Vernon Wilson,
             The reviewers of the application commented that:  1) planning for and
             representation of the St. Louis area on the RAG seemed weak (the Bi-State
             RMP later encompassed this area); 2) the program was vaguely defined; and
             3) the apparent emphasis on community service was most impressive, although
             not wel-l-budgeted for.  The award was made in June 1966.

             II.  Operation     o ram
             A.  Early Background - In October 1966, the Region submitted an application
             for three operational pilot projects, which was deferred for a site visit.
             At the same time DRMP suggested to the Region that a more comprehensive
             operational grant application be prepared, with the possibility of the
             becoming one of a few timodel programs."  The Region explained at a site
             visit in 1969 that Dr. Wilson gathered together several members of the
             University faculty interested in RMP and spent "forty days in a DC-3" with
             them traveling around the United States looking at possible types of
             innovative projects to develop.  The Region then submitted an application
             containing 20 additional projects, three of which were community programs,
             three population and data studies and the rest computer and bioengineering
             activities.  Submitted at a time when the RMP budget for 1970-71 was
             projected for $200 million, the intention of these latter proposals was
             to use the computer and bioengineering resources at the University to
             develop and deliver diagnostic and therapeutic assistance to practicing
             physicians isolated from the medical center.  The Region was site visited
             in November 1966 with a favorable report, and the Region became one of the






        Missouri Regional Medical Program        -8-                RM  00009  5/71
        first RMP's to become operational when the award was made  in  April  1067,
        at a level considerably below that requested.  Three  conditions  were
        placed qn the award: 1) the RAG add  minority  group  representatives;
        2) more attention be given to the urban ghetto areas; and 3) more
        emphasis be placed on cancer programs.  During this same year two-
        supplemental applications for project support were submitted:
        Project #19 - Automated EKG in a Rural Area, was approved and a
        proposed stroke center at Kansas City General Hospital was disapproved.
        At the beginning of the second planning year  (July  1967).,another  site
        visit was held to look at several supplemental project requests.  The
        visitors were impressed with the concept of regionalization and the
        Region's intention to phase-out RMP support after three years of funding.
        In October 1968 Dr. Arthur Rikli replaced Dr. Vernon Wilson as
        Coordinator.

        At this point in its history, the program seemed to reviewers to separate
        into decided program areas.
        A. Computer and Bioengineering  Activities  Eight  projects  were  funded
        in this area: multiphasic screening, mass screening  -  radiology,  automated
        patient history acquisition system, data evaluation and computer simulation,
        computer fact bank, operations research and  systems  design,  bioengineering
        and automated EKG for rural areas. Both DRMP and  MRMP  r6alized  that
        these were developmental activities, but both hoped that  after  three
        years, they would be able to make definite contributions  to  the  delivery
        of health care. At that time of the  second  year's  continuation  review
        of the original projects, the Region submitted a request for $860,000
        more than the committed level, foi-expand computer and  bioengineering
        activities as originally planned. A  restriction  of  $240,483  primarily
        for A and R, which involved computer facilities,,was placed on  the  award,
        and a technical site visit was recommended.  Although the Fall 1968
        visit was only for one dgy, reports of progress on the individual activities
        were discouraging.  Within the next few months, the Region proposed
        support in their third operational year for a ilinical  core  resource  which
        involved approximately $800,000 for staff  in  the  computer/bioengineering
        projects in addition to the ongoing projects in this area.  As a result
        of the critical site visit comments and the uncertainty about the
        concept of clinical core, Council recommended that  these  activities  be
        reviewed in depth during a site visit that year.
        In October 1969, a major site visit was held which  included  three  peer
        reviewers with expertise in computers who spent two  days  assessing  the
        activities. As a result of the site visitors'  conclusion  that  none  of
        the activities had yet demonstrated success in improving  the  delivery  of
        health care or in enhancing regional, cooperative arrangements, Council
        in MArch 1970 recommended that the Region reduce its expenditures for
        these activities and then phase-out RMP support completely by June 30, 1971.
        The project was awarded approximately $1. million for its  fourth  and  final
        year of operation in 6rder to combine the former eight  parts.to  make  the







            Missouri Regional Medical Program    -9-                  RM 00009  5/71

            system compatible, and to field-test the module in one  physician's  office
            in Salem, Missouri.

            At the time of staff review of the last application from Missouri in
            July 1970, RMP staff requested additional information about the Advanced
            Technology Proposal.  The Region's replies raised concerns which rtlated
            to: 1) the liklihood that the components would be  completed,  made
            compatible and fully operational in the private physician's office  in
            Salem in sufficient time to test enough patients to obtain  meaningful
            results within the project time period; 2) the coordination  necessary
            to cohese so many different elements; 3) the detail  and  comprehensiveness
            in workscope timetables and planning needed to bring the  divergent
            subprojects together in an orderly and coordinated  manner.  The  Director,
            RMPS, recommended that the Region call in outside experts in systems
            design and computers, epidemiology and clinical medicine to  review,
            monitor and make suggestions for appropriate changes in order that the
            project would be completed by June 30, 1971.

            A site visit including Dr. John Hirschboeck, Wisconsin RM.P Coor inator
            and a member of the October 1969 site visit team; Dr. Morris F. Collins,
            Director Medical Methods Research, Perman6nte Medical Group and
            Dr. Martin D. Keller,, Department of Preventive Medicine, Oiio State
            University, was held by the Region to the Salem operation in January 1971.
            The report, a copy of which has been forwarded to RMPS, is  enthusiastic
            about the results.

            The Region's proposal for continuing these activities is discussed  on
            pages 16-18 in the summary.

            B.  Camunity-Based Programs

            MRMP's early efforts in developing community-based programs were  in
            Smithville and Springfield. Smithville in northwest  Missouri  evolved
            and was praised by national reviewers as a model for small  communities  in
            developing total care facilities, including continuing education opportunities,
            which have become self-supporting and cost-efficient.  The  Smithville
            project  began in April 1967  and terminated after three years of support.
            The Springfield Cardiovascular Program in southwest Missouri was  an
            early effort in building linkages to rural practitioners.  The  project,
            which was expanded and reviewed as Project #58 in 1970, appeared  to
            site visitors to be an effective instrument for subregionalization  of
            health services and education.

            There were other early subregional efforts such as a  Comprehensive Cardio-
            vascular Care project at Kansas City General (#27), a stroke  pilot
            project at the Kirksville Clinic of Osteopathy and Surgery (#28),  a
            regional program in rheumatic fever prevention using a detail man
            (#32), and a radioisotope cancer program in Cape Girardeau (#37).

            In the Region's third operational year (1969-70) the  subregional  projects
            began to experience some difficulty during their review at the  national







                                                                       RM  00009  5/71
         Missouri Regional Medical  Program      -lo-
         level, which had profound  repercussions  in  the  Re9ion.  At  a  time  when
                                                             9
         the computer and bioengineering activities  were  being  funded  at  a
         $2,4 million level, the disapproval in two  review  cycles  of  an  intensive
         care program in Sikeston, a stroke program in Joplin, a coronary care
         unit in Osceola, and a comprehensive  rehabilitation  program  in  Le' banon,
         inadvertently conveyed a false--impre-asioTi to the Region of the --
         national reviewers' wishes concerning the future emphasis of the Program.
         While each project was  viewed  individually  and  returned  for  substantive
         technical reasons, the cumulative effect on the Program of these individual
         actions was finfdrtanate.
         The site visitors in October 1969 heard repeatedly about the Sikeston
         community. After a study of  the  site  visit  findings  concerning  the
         discouraging results  of  the  computer  bioengineering  investment  and  the
         lack of emphasis  on  community-based  programs,  Council  in  December  1969
         recommended that the Region f4i;vise and resubmit  these  community-
         based projects during the next review cycles.  In the February-March 1970
         review cycle, Council did approve the resubmissions from Joplin (#50)
         and Sikeston'(#51) and a renewal  of  the  Springfield  effort  (#58).
         The Region's community-based requests since then  have  not  fared  so  well.
         The Region submitted a comprehensive  health  care  system  proposal  for
         the Cameron Community in northwest Missouri  (#60),,  an  intensive  care
         and rehabilitation project  in  Branson  in  southwest  Missouri  (#61),  and
         a comprehensive health care system  proposal  for  eleven  hospitals  in  the
         Green Hills area (#65).  While  Council  recognized  the  earlier  advice
         to the Region to encourage  community  development,  it  was  concer ned   with
         the types of support requested by  the  Region  in  each  project.  Items
         such as equipment, staffing for provision of services and a communications
         system for centralized cost  accounting,  reviewers  felt  should  be  under-
         written by the hospitals and  not  by  RMP.  In  addition  weaknesses  in
         documenting need, describing what would be done  and  h;w  it  would  be
         evaluated indicated the need for more  assistance  from  the  MRMP  Core
         staff. The Region's  revised  submissions  of  these  proposals  are
         summarized in pages 20-21 of this summary.  Descriptions of new activities
         in this area are on pages 1.8-20 of this.summary.
         Until the last year there was little  evidence  of  RMP  activity  in  Kansas
         City, other than the cardiovascular project at Kansas City General  (#27).
         The October 1969 site visitors found that the Core office was not staffed,
         and the Kansas City  Liaison  C-  ittee  had  become  inactive.  However,
         with the development of a new medical school  in  Kansas  City  and  the
         proposed involvement in the Wayne Miner Neighborhood Health Center
         through the  Hi-Blood  project  (#46),  prospects  looked  favorable.  During
         the past eighteen months, the  Kansas  City  Core  office  has  been  staffed
         and the CHP b Council  now  serves  as  the  liaison  committee  for  MM  and
         KRMP in Kansas City.  A Core supplement was disapproved by the November 1970
         National Advisory Council because the proposed activities were too
         diffuse and did not appear to be  correlated  with  the  rest  of  the  MRNP.
         This application again  proposes  supplemental  core  funds  for  Kanszw'Ctry
          aA& two projects, #78 and #70'described on page-  23'  '  of  this  summary.






             Missouri Regional Medical Program                               RM 00009 5/71

             D.  Continuing Education and Training

             The third major aspect of the Missouri program has been continuing education.
             While not designated as such, many  projects  had  continuing  education  or
             training as a major feature.  There seemed to reviewers and site visitors
             to the Missouri program to be two concurrent and separate trends in this
             area developing in the Region.  One  was  the  excellent  efforts  fostered
             by individual project directors independently of the University 14
             projects such as Smithville, Springfield, and Cape Girardeau.  The other
             was the University-connected activities, such  as  the  stroke  ICU  and
             cardiac ICU training proposals at the medical  schbol  (#25  and  #26)  and
             the telecture series, which linked community hospitals throughout the
             Region with the medical school by  two-way  radio  (#33).  This  side  of
             @'s  continuing  education  program  seemed  to  be  supporting  continuing
             education competence within the  medical  school  without  building  any
             visibility for RMP.

             A Core-Continuing Education resource based  at  the  medical  school  was
             submitted by MRMP in mid 1969.  Its  lengthy  review  history  is  described
             on page 23 of the summary, but  its  difficulties  in  gaining  approval
             aty be Attributed partly to its  emphasis  on  developing  an  institutional
             organization to  provide  continuing  education  rather@than  developing
             programs which would focus on improving patient care.  Other factors,
             including the size of the request, are discussed as background to the
             revision in this application.  Other  proposals  denoted  by  the  Region
             as primarily continuing education are included in this section.

             In conclusion, this Region is at a  critical  point  in  its  history.  Over
             a year has elapsed since the major program  site  visit  and  the  Review
             Cr  ittee and Council review which made substantive recommendations about
             the direction of the program. The  Region  is  now  preposing  a  three-year
             plan which is an outgrowth of  its  total  experience  since  1967.  The
             regional objectives and the  three-year  plan  to  address  these,objectives
             follow.


             Regional Goals

               The Missouri RMP has developed the following program goals:

               1.  Through cooperative arrangements  to  accelerate  health  and  medical
                   innovations and demonstrations.

               2.  To develop a balanced program of problem-and-patient-care oriented
                   continuing education for health professionals.

               3.  To develop a relevant data base  and  the  data  haidling  capability
                   to permit effective project and program evaluation.

               4.  To stimulate the prevention and  early  detection  of  heart  disease,
                   stroke, cancer and related diseases.





        Missouri Regional Medical Program        -12-              RM 00009 5/71
           5.  To stimulate lay health education - information programs,
               emphasizing prevention and early detection of diseases.
           6.  To strengthen the diagnostic and treatment capabilities of
               the region with respect to RSC & RD..
           7.  to expand and'strengtnen long-term-care, rehabilitation-and
               home care for HSC & RD.
           8.  To develop a comprehensive health services project in each
               of the six subregions.
           9.  To facilitate health manpower recruitment,, thus helping the
               physician make optimum use of his knowledge and skills.
           10. To achieve close coordination with other health and
               health-related programs.
           11. To co-sponsor'activities and programs with neighboring
               Regional Medical Programs.





                                               -13-                        PM 00009   5 /71
               Missouri RMP



               PRESENT APPLICATION

               Developmental Component

                     First Year                 Second Year           Third Year
                      $400,000                   $400,000               $400,000

               The Missouri RMP  states that its developmental component  activity  is
               expected to have  two benefits: greater responsiveness of-the  IARMP'@s
               objIectives to changing regional needs, and increased effectiveness of
               the MRMP Pi-opram.l.n achieving these objectives.

               Proposed developmental activities Incl.ude:

                    1. Providing opportunities for a wi(ler  variety  of  professional
                         and lay input into the Region's decision-making bodies in
                         reg8rd to reshaping objectives.

               The Region might provide part-time support and secretarial. service for
               one member each from the I.aw school, an allied health profession, or a
               minority group, who would.study RMP legislation and the Health
               care system from their vantage point,  recommending  fresh  approaches.
               This might lead either to revamping of objectives or to proposal develop-
               ment,

                    2.  Selectively supporting the development of proposals which
   0                     specificAll,y address regional objectives.
               Developmental component funds might be used  to  encourage  development  of
               the most relevant projects proposed to the Region by letter of intent
               each year.  Support would include vart-time support of the project
               director, support for a research associate, secretarial help, evaluation
               consultation, and for activity required to obtain co-operation and
               coordination in the project area.

                         Funding surveys and feasibility studies to ensure development
                         of proposals which would be more effective  in  reaching  program
                         objectives.
               Develonmental funds might support  both the studies which  would  val.idate
               the assumptions usually made about expected  benefits  of  proposed  activ-
               ities. as well as the dita-gethering activities necessary for developing
               and evaluating a proposal being written or considered.
                    4.    Funding activities which would themselves I.ead  to  achieve-
                         ment  of Regional objectives.

               This  would  allow greater flexibility in the Region program.  The develop-
               mental   component could provide total support for  short-term  projects  of
               I imi ted scope, a Rwell as partial or complete support of projects awaiting
               RMPS approval should the RAC consider earlier funding necessary.





                                                                       RM  00009   5/71
           Missouri RMP                 -14-


           dminiptrativp procedures for Allocating Devel.opment
                                                                a]  Component  Funds
           The T)evploinmental component will be managed primarily by core staff.
           Requests will be submitted for approval to the RAC, and funds awardecl
           an(] managed by the regular administrative support system.
           CORE                                                 Fifth Year:
                                                                $1,474,165
           The Core of the MRMP.has been organized into three offices:
           1. The Office of the  Coordinator,  which  provides  administrative  support
           and professional consultation in electronic data processing, fiscal affairs,
           information and management.  An Associate Director for Continuing Education,
           who will be responsible for all continuing education activities in
           projects and in the district offices, will be added to  the  Office  of  the
           Coordinator.


               Fifth Year Request
                   $647,795
           2. The Office of Operations, which  is  primarily  responsible  for  program
           implementation and evaluation.  When projects have been funded, the
           Office coordinates and monitors the progress  of  ongoing  projects  through
           in-house site visits in the next-to-th@e-last year of the projects,
           district project directors meetings,  and  project  directors  meetings  via
           the telelecture network (not yet initiated).   This  Office  also   requires
           quarterly progress reports. In order to  help  regionalize  some  of  the
           results of the bioengineering projects, the "detail  man"  of  the  MRMP-
           funded rheumatic heart disease project has  been  added  to  the  operations
           staff. Consultants are made available to  project  directors  in  the  areas
           of communications, continuing education,  medical  and  scientific  affairs,
           hospital and allied health affairs, computer science and evaluation.

               Fifth Year Request
                   $181,981
               Ihe Office of Plannin_gwhich develops an overall  MRMP  plan  an@  major
           disease catep6ry plans to  be  implemented  through  projects.  This  Of'ice
           works with neople developing proposals and staffs  the  meetings  of  the
           MRMP A,Ivisory Council, Project  Review  Committee,  Liaison  Committee  and
           Subregions! T,ieison Committee. The Program  Metho(lolop,,y  Unit,  formerly
           funded as a project and  with  expertise  in  epidemiology,  statistics  and
           Flats processing, is incorporated into  the  Planning  Office.  It  provides
           various data for project purposes and for  the  RMP's  planning  purposes
           by utilizing existing sources of date  and  occasionally  collecting  its
           own.  Evaluation is also the responsibility of the Planning Office.
           Although presently placed within the Planning Office, it appears from the
           organizational chart on page 51 that  the  district  offices  will  be  made




              Missouri RMP                 -15-                         RM 00009  5/71


              directly responsible to the Coordinator.  District consultants have
              been chosen for each of the districts (Kansas City,  Northwest,  North-
              Past, Southeast, Southwest and Central). District  offices  in  addition
              to the Kansas City office will be developed over the next  three  years.

                  Fifth Year  Request
                    $458,11'4

              The Kansas City Area Planning Office provi(les.planning activities  for
              the five-county areas of Jackson, Clay, Platte, Ray and  Cass  Counties
              in support of MRMP activities.  Its staff includes a Planning Director,
              Assistant Directors in communications, community services, allied health
              and professional relations. Activities of the Kansas  City  Area  Office
              (described in pages 1.64-175 of the application) include efforts in
              planning phy6ician's assistants program, restructuring nursing curriculum
              at the junior college level, developing career-ladders for L.P.N.'s
              and studying the feasibility of a two-way medical TV network.

                  Fifth Year  Request
                     $186,276

              Coordination and some overlap of membership is planned between the MRMP
              area committees and CHP (b) councils4  The experience of the University
              Extension Division, which has offices throughout the state,  will  also
              be tined in developing public education programs at the subregional level.

              The MRMP Core has also been administering the state's $200,000 appropriation
              for hemo(lislysis and is presently involved in developing a multi-regional
              renal disease program with the Kansas and Bi-State RMPS.

              The total number of positions requested is 80 (71.5 F.T.E.):  of  these
              80 positions, 58 are presently fil.led.

                  Sixth Year                                   Seventh Year
                  $1,687,81-1                                  $1,896,617

              Descriptions of these terminating Program Guidance Projects can be found
              in the application following the core section.

                        Communications Research Unit
                   #11 - Population Sturly Group Surveys
                   #14 - Automated Hospital Patient Survey



              Projects

              The Region has  orgeniz ed the discussion of their projects  into  various
              subject areas in their application.  In describing the proposed activities
              in the summary, Staff.has changed the Region's arrangement somewhat,
              in order to better align the project discussion with the background




                                         -16-                         RM 00009  5171
            Missouri, RMP

            material,  The three major sections  fe    Computer and Bioengineerin@.,
            Projects, Community Service Projects and  Continuing Education Projects.
            Computer and Bioengineering Projects
            While the Advanced Technology Project  and  its  eight components (Multi-
            rhasic Testing, Mass  Screening  Radiology,  Automated Patient History
            Acquisition System, Date Eval.ustion and Computer Simulation. System,
            Computer Fact Bank, Operations Research and Systems Design, Biomedical
            Engineering and Automated EKG in a Rural Area) are terminating as such,
            the work begun (luring the past four years will be continued in the
            following five projects:
                                                                  Requested First Year
            Project #64 - Bioing rumentati n                          $46-.834
            This project was previously approved  by  Council  but has not yet been
            funded. It was developed as a result  of  one  of  the recommendations of
            the October 1969 site visit report  which  urged  that the medical instrument-
            ation servites of the biomedical engineer in t e Biomedical Engineering
            Project be made more widely available to  hospitals  throughout  the  Region.
            The project would help regional hospitals optimize their utilization of
            patient monitoring instrumentation by:
                 1)'Giving  engineering counsel in ICU-CCU design and  in  the  selection
                    of biomedical patient care instrumentation, thereby assuring
                    patient protection against accidental electrocution;
                 2) Providing specialized instruction for engineers and technicians
                    in routine maintenance procedures, recognition of substandard
                    operation and safety practices; and
                 1) conAucting seminsi- a on request within regional institutions to
                    instruct medical and paramedical members in techniques for
                    ontimum utilization of their patient care instrumentation.
                Second Year                                       Third Year
                 $47,708                                           $50,259
                                                                  Requested First Year
            Project #69 - Computer Processed Diagnostic Aids          $290,710
                           in a Rural Area
            This proposal is an extension and field testing of the automated
            electrocardiogram with the addition of new diagnostic aids, including
            artificial pacemaker analysis,-cardiac arrhythmia analysis, exercise
            ECG analysis of lung function by spirogram and screening analysis of
            the phoncardiogram. The project  plans  for  38  stations  and  50,000  ECG's
            per year. A special sim would be to  provide  aid  to  the  smallest  medical




                Missouri RMP                  -17-                           RM  00009   5/71


                facilities - community  hospitals  under  100  beds,  group  practicies  and
                solo practitioners  -  at  a  reasonable  cost.  The  proposal  also  offers
                training for medical and electronic service personnel.

                    Second Year                                          Third Year
                     $178,882                                              $122,716

                                                                      Requested  First   Year
                Project #71 - Automated Patient Iiistory Acquisition         $75,070
                               System Field Test

                The Durpoiqe of this proposal is   to field test this approach to acquiring
                a meiical history in the  offices  of  a  three-man  internal  medicine  group
                practice in Cape Girardeau.  The APHAS program has designed the question-
                noire in laymen's language with anatomical sketches and cartoon characters
                an,! a computer program to present these questions on the computer terminal.
                When the  patient  finishes  the  questionnaire  (usually  in  45  minutes),
                the computer prints out a summary of the patient's responses to the
                questionnaire as well as  the  positive  responses  to  symptoms  of  diseases
                for  the  anatomical  area  troubling  them.  Some  preliminary   evaluation
                has been done of the patient's responses.

                                                                       Requested  First  Year
                Project lt72 - Automated Physician's Assistant             $153,537
                The project woul.d attempt to  determine  the  effectiveness  of  a  computer-
                related system of medical  tests  designed  to  function  as  a  "physicign's
                assistant."  The total package would consist of the APHAS questionnaire,
                an EKG, 12 blood  chemistries,  blood  pressure,  height,  weight,  eye  test,
                hearing test, chest X-ray, spirometry, tonometry4 Achilles tendon reflex
                and a  phonocardioscan.  A  prototype  of  this  system  which  is  presently
                installed in a  physician's  office  in  Salem,  Missouri,  is  funded  until
                June 10, 1971.  Further  support  is  requested  to  test  the  effectiveness
                of each of the  components  and  permit  further  evaluation  of  the  system
                by the physician and his patients,
                                                                      Requested  First   Year
                Project #75 - Biomedical Information Service              $142,428

                Formerly known  as  the  Computer  Fact  Bank,  the  Biomedical  Information
                Service  proposes  to  tie  together  library  activities  and  systems  for
                information coordination and transmission.      While  the  present   system
                has developed a system of storage and retrieval of biomedical information
                with ten operating outlets  in  the  Region,  the  BMIS  would  utilize  the
                102 tplectivp  units,  15  teletypewriter  units  of  the  ECG  project  and
                27 Patollitp Extension Heal.th Information Centers to be developed.

                The proposal hopes  to  increase  smaller  medical  library  utilization  by:
                1) holding workshops, in-service training and continuing education
                sessions for library staff personnel, hospital administrators and
                physicians;  2)  arranging  for  interlibrary  loanso  information   exchange
                and bibliographies  and  specific  literature;  and  3)  provision  of  con-
                oultation services.

                    Second Year                                     Third Year
                     $288,40-'                                      $259,440






                                                                     RM  00009   5/71
          Missouri RNP                 -18-

          The MRMP Advisory Council has recommended that this proposal incorporate
          the services of the Health Sciences Libraries System and the Drug
          information Central (#62).

          Community Service Projects

          The terminating project is:

               #29  -N.E. Missouri Cooperative Stroke Pilot Project

          Continuing Projects with Committed Support art:

               #46   Hi-Blood
               #50   Joplin Stroke Prevention
               #51   Sikeston Intensive Care Unit
               #52   Health Careers
          Continuing Projects with no committed support (these proposals were
          originally approved but unfunded; however, the Regton has elected to
          initiate them with carryover or by rebudgeting):

               #36 - Missouri Cervical Cytol.ogy
               #37 - S.E. Missouri Radioisotope
               #38 - Homemaker Health Aide
               #39 - Phonocardioscan
               #43 - Diabetes in Children
               #62 - Drug Information Central

          New Projects
          In these projects, the Region provides services either to several
          locations or for the entire region on a community basis as part of a
          plan to extend regional activities to the patient's bedside.
          Projects #76 (Mobile R6habilitation Service) and #77 (Cardiac Care
          Missouri) both relate to objectives:  1) cooperative arrangements;
          2) continuing education; and 6) diagnostic and treatment capabilities.
          Project #76 also relates to objective 7 - rehabilitation and home care.
          Project #68 (Cooperative Prevention for Cardiovascular Pulmonary Problems)
          includes not only objectives 1,2,6, and 7 but also objectives:
          4) prevention and early detection; and 5) lay education.
          Project #80 (Cameron Health Care) is rel.ated to 10  of  the  11  Regional.
          objectives and #81 (Branson Intensive Care) includes all 11 of the
          Region's objectives.
          Project #25R- (Stroke  Intensive  Care)  relates  to  Regional  objectives:
          2) continuing education; 6)  diagnostic  and  'treatment  capabilities;  an
          8) development of community health services.




                Mi@ssouri RMP                  -19-                      RM 00009  5/71


                Pro  t ft68 - Cooperative Prevention
                 jec                                for Cardiovascular Pulmonary
                             kP'rOblems
                This project would involve hospitals in the Kirksville area serving
                seven counties in Northeast Missouri.  It is based on the Northeast
                Missouri Cooperative Stroke Project (#29) now terminated,  Objectives of
                the new project are:  1) initiation of innovative continuing education
                programs for physicians and allied health personnel. (coordinated with
                Columbia and Springfield graduate nursing courses) and a community
                education program emphasizing prevention; 2) development of a preventive
                and therapeutic activity center in collaboration with the Division of
                Health and Physical Education of the Northeast Missouri State College;
                and 3) establishment of progressive care and rehabilitative programs
                for cardiovascular-pulmonary patients as a part of the new expansion  at
                the Kirksville Osteopathic Hospital.

                      First Year                            Second Year
                       $67,148                              -T67,095
                Project #73 - Regional Emergency Service Quantitative Up@a(linp, (RESQU)
                This it a planning effort, involving an eight-county rural area of
                Southwest Missouri, which would establish an organized ambulance service
                ,capable of getting patients to medical facilities in optimum condition.
                Upon successful implementation in these counties, the program would
                be expanded to the remaining 25 Southwest counties.

                      First Year                              Second Year
                       $38,888                                   -0-

                Project #74 - Platelet Plasmapheresis Program
                This Project will establish an efficient, full-time and ultimately
                self-sustaining plasmapheresis program in the southwest Missouri subregion.
                When implemented at St. John's Hospital in Springfield, the program could
                accommodate patients in any southwest hospital where platelet transfusions are
                (lone.  Primary purpose of the project will be provision of compatible
                platelet infusion.  Tissue type and liisto-compatibility techniques would
                also be initiated along with this project.

                     First Yes                               Second year
                      $47,627                                 $37,595

                Project #76 - llobile Rehabilitation Service
                This project would provide rehabilitation services, now  unavailable  to
                rural areas of southwest Missouri, by establishing a mobile service under
                the supervision of an orthopedic surgeon and in consultation with a



           Missouri RMP                      -20-                   RM 00009  5/71


           phyiistrist.  Two teams, each comp  osed of a physical therapist and a
                I
           nurse a side (with part-time access to an occupational therapist), would
           provide 20 days O'f service each month to outlying hospitals and nursing
           homes.

                  First Year                                   Second Year
                     $93,276                                    @94,625

           Project #77 - Cardiac Care Missouri
           This project is designed to provide improved care to patients with
           acute cardiovascular illness through:  assessment of present care and
           consultation on  corrective  measures;  coordination  of  ongoing  programs;
           education of providers, patients and their families; establishment and'
           improvement of communication (such  as  tel.e-transmission  of  EKG's);  and
           assistance  in  arranging  continuing  clinical  consultation.  The  project
           structure will include a Missouri Heart Association "task force", providing
           assistance to any community or subregion in Missouri, and cardiovascular
           care committees in each participating hospital relating both to volunteer
           staff in each subregion and to  an  MHA  Cardiovascular  Care  Committee  of
           12 local  physicians.  Initially,  project  activity  would  concentrate  in
           southeast Missouri.

                 First  Year                                  Second Year
                    $184,651                                    $159,554

                 Third  Year
                  $153,822

           Project #80 - Cameron Health Care
           This is a revision of a previous submission which was disapproved because
           of weaknesses in evaluation and educational design and because it requested
           support for services  which,sbould  be  financed  by  the  community.  Based
           at the Cameron Community Hospital, this project is designed to upgrade,
           through physician education programs, the diagnostic and treatment  ,
           capabilities in categorical diseases of 13 area private practitioners
           and to organize and train supportive medical personnel.  The use of
           consultants from neighboring institutions should help reduce the isolation
           of the private practitioners.  The project will also provide:
           appropriate patient care equipment from hospital funds, effective
           emergency care in ambulances, rehabilitation services, an(] trained
           personnel for follow-up care through a home health agency.

                First Year                                      Second Year
                 $11,901                                          $10,463

                Third Year
                 $10,463
           Project #81 - Branson Intensive Care and Rehabilitation Project

           This revised proposal was turned down originally primarily because
           it-appeared to represent the  interests  of  a  single  institution,  rather
           than a truly regional effort.





                Mi.asouri RMP                      -21-                      RM   00009   5/71


                This project is designed to provide immediate access to       hi.gh   quality,
                low-cost health care at the Skaggs Community Hospit8l, establishing
                cooperative  arrangements  with  referral  centers,  with   special   emphasis   on
                improving service  to  the  large  number  of  elderly  disadvantaged  and  rural
                poor in the  area.  To  do  this,  the  project  provides  for  both  training
                and  continuing  education  of  nursing  personnel  technicians  and   Doctors
                of the hospital medical staff.  Consultants will be drawn from St. John's
                Hospital,    Sprin gfield  (intensive  care)  and  the  U.M.  Department  of
                Physical  Medicine  (rehabilitation).  The  proj'ect  will  incl.ude   evaluation
                of  post-treatment  results  compared  to  past  results  and  results  at
                other   hospitals.

                      First   Year                                        Second Year
                        $38,965                                            $28,460

                      Third   Year
                        $9,000

                Project #83 - Green Hills Cooperative Health Care Project

                Disapproved by   the  November  1970  National  Advisory  Council  because  it
                also requested   support  for  services  and  equipment  which  would  ordinarily
                be underwritten by  the  hospitals,  the  project  has  been  revised  and
                resubmitted by the Region.

                This project is designed to combine the resources of 11 cooperating
                hospitals in  the  12-county  Green  Hills  medical  service  area  to  ensure
                improved  quality  and  quantity  of  health  care,  with  efficient,  economical
                use of resources and comprehensive care for the entire area.

                This effort  wil-I  require  establishment  of  a  communications  network
                serving  all  11  hospitals,  and  development  of:  techniques  for   continuing
                education  of  all  medical  personnel,  adequate  ambulance  service,   adequate
                coronary  and  stroke  emergency  care  in  all  hospitals,  an  areawide  inhal-
                ation  therapy  program,  an  areawide  comprehensive   rehabilitation   service,
                and a home health agency for the area.

                      First   Year                                   Second Year
                      $95,661                                          $95,077

                      Third   Year
                      $950077

                Renewal Projects

                Project #25 R - Stroke Intensive Care Unit

                This project, located  in  a  temporary  unit  at  the  UMMC,  will  continue  to
                examine the  effects  of  stroke  intensive  care  nursing  on  mortality  and
                morbidity  of  stroke  patients.  Presently,  personnel   in   the   temporary




           Missouri RMP                      -22-                      RM  00009   5/71


           unit have become efficient with the electronic equipment and are preparing
           for the opening of,a  new  ICU.  Nurses  have  already  demonstrated  ability
           to detect new or progressive neurological changes in the stroke patient.
           Of the 15 patients admitted to the  ICU,  twelve  survivied;  while  of  the
           16 admitted as a control group to the regular care group, nine survived.
           Continued random admissions to  the  ICU  and  increased  patient  referrals
           will.provide an opportunity to conclusively document these results.

                Fourth Year                               Fifth Year
                 $206,964                                   $52,272


           continuing Education Projects

           The terminating projects are:

                #27 - Programmed Comprehensive Cardiovascular Care
                #33 - Continuing Education for the Health Professions (telelecture)

           continuing Projects with, Committed Support are:,

                #55 - Cameo
                #58 - Cardiovascular Education and Evaluation



           New Projects

           The new continuing education projects in this application include a
           variety of  proposals  which-address  themselves  to  in-service  training,
           improvement of health care  problems  related  to  laboratory  services  and
           two regional  approaches  to  the  organization  of  continuing  education.
           Projects #79 (Improvement  of  Pharmaceutical  Services)  and  #78  (COMPACT)
           are related to objectives: -1) cooperative arrangements and 2) continuing
           education. Project  #70  (Training  in  Arrhythmia  and  Resuscitation)  also
           relates to objective 2.
           Project #67 (Health Education in  Cancer  Hospital)  relates  not  only  to
           objective 2 but includes aspects  of:  9)  health  manpower;  6)  diagnostic
           and treatment capabilities, and 7) rehabilitation and home care.

           Project #67 - Health Education-in A Cancer Hospital Setting

           This project is a trial of  comprehensive  health  education  in  a  hospital
           setting, Ellis Fischel State  Cancer  Hospital.  in  Columbia.  This  effort
           will include development, implementation and evaluation of education
           programs for patients and  their  families,  all  hospital  employees,  and
           the public. Within  two  years,  concepts  developed  in,this  project  will
           be shared with other facilities in the State through workshops and
           consultations.


               First Year                                   Second Year
                $31,079                                       $33,836

               Third Year




                Missouri Me                 -23-                        RM 00009  5/71

                Project #78 - Cooperative Ongoing Medical Health Participation and
                             Continuing Teacbing
                This project will establish regular inter-hospital  departmental  meetings
                to upgrade educational programs in metropolitan Kansas  City  hospitals
                which will be utilized by the new medical school  for  clinical  teaching.
                COMPACT uDuld coordinate meetings of each specialty  in  conjunction  with
                joint hospital departments so that multiple hospitals would be represented.
                A review, or coordinating, committee for each specialty  or  department
                would coordinate clinical review with a scientific session.  Each
                department, then, would share in eight joint meetings  annually,  as  well
                as in four administrative meetings at their respective hospitals.

                     First Year,                              Second Year
                       $51,440                                  $47,480

                     Third Year
                       $47,778
                Project #79 - Improvement of Pharmaceutical Services - Rural Health
                             Care Institutions
                Sponsored by the University of Missouri (Kansas City) School of Pharmacy
                and Division of Continuing Education, this project will evaluate
                pharmaceutical services in hospitals and nursing homes - particularly
                in rural areas - to determine for each:  current status of services,
                facilities available for such services, and  local  pharmacists  available
                to provide proper services.
                This information will be used to plan and  implement  needed  improvements
                in each institution through a cooperative effort of project staff and
                institution personnel.
                    First Year                                   Second Year
                       $73,990                                   @73,610

                    Third Year
                       $73,610
                                                                               First  Year
                Project #82 - Continuing Education - Coordination Project         $114,062
                This proposal has had a lengthy review his tory.  Originally submitted
                in mid-1969, it was deferred by Council for  further  consideration  by
                the October 1969 site visitors, reviewed at the  site  visit,  returned
                for revision by the December 1969 Council, resubmitted  by  the  Region
                in mid-1970, and again disapproved by Council.
                The substance of the cumulative criticism of  this  proposal  related  to:
                1) the emphases on developing an organization  rather  than  on  designing
                programs geared to improving patient care; 2) lack of date used to
                identify needs; 3) lack of agreement among university, RMP   and   project
                representatives about the role of the extension agent; 4) the absence



         Missouri RMP                     -24-                    RM 00009  5/71

         of plant for coordination of the educational benefits from other MRNP
         activities, particularly community-based ones, with the proposed activities
         of this project; 5) lack of'systemmatic evaluation; 6.) the size of the
         request ($2,000,000 over A five year period) and 7) the need for more
         full-time direction o f such a comprehensive activity.
         Briefly, this proposal would attempt to develop the framework of voluntary
         participation, interaction and cooperation  of  continuing  education
         agencies and institutions which are necessary before a region-wide system
         of continuing education can be established.  Cooperative arrangements
         would result from three related activities:
               1.  A Continuing education inventory would he initiated,   with
                   continuous updating, of all continuing education activities
                   provided by institutions in the Missouri subregions.  This
                   would identify duplications, overlaps and gaps  in  overall
                   educational programming in the Region.
               2.  Teacher-consultant linkages would be developed consisting of
                   a specially assembled cadre ot representative health professionals
                   working with Regional counterparts in specific locations, to
                                ation needs common to  each  profession.  The'
                   identify educ
                   consultants will also provide links to the Advisory Committee
                   on Continuing Education
               3.  A local educational coordinator in each of five subregions would
                   give individualized assistance to health care institutions in
                   developing continuing education programs tailored to their
                   own needs. (A sixth subregion will receive this,help from
                   central project staff.)  These coordinators would be part of
                   Core staff.
              Second Year                                    Third Year
               $142,940                                        $256,245
              Fourth Year                                     Fifth Year
               $225,172                                        $212,172


          Renewal Projects


          Renewals
          Project #26R - Training in Arrhythmia and Resuscitation
                          (Community Hospital Nursing Staff)
          This project would provide two weeks of training at UMMC in monitoring
          and resuscitation techniques for acute cardiac conditions to community
          hospital nursing staffs.  The course will consist of one wee,k's initial
          training and a week's advanced training 3-4 months later, utilii,ing the
          Rocom Multi-Meals Instruction System and observation  t the Coronary
          Care Unit, UMMC.  Approximately 100 nurses would be t:ained per year
          at the UMMC plus another 50 in community courses.
               First Year              Second Year              Third Year
                                        @@- -1,                 - tri IR7




                                                       25-

                                              O'. i@'rat -
                                                       -1-ii, EDUCA'I-ION, Al@D WELI:-ARE

                                 HEALTii sE--.r@vICt!5 At'.D t,4LtJTAL IIF--AL-Iti ALti,iNl';T,tATION


           ate:           March 8, 1971

         .Y to
      Alin Of.-
        Subject:          Staff Revie@.., of the Missouri      @@iP's  Tri-ennial- Application, R@109.

           To:            Acting I)irecLor
                          Regional Medical Programs Sc@rv:'
                          THROUGH:
                                       Chairman of the Month


                          Chief,   Grants   Review
                                                     Branch,@

                          ,Chief,  Grants Management Branch

                          Acting   Chief, l@opioiial Dc,,vel.opi-tic.-iit Brai-L


                          Staff met to rc,V!.C-v7 the triennial. application stil.)niitL(-@d by ti)(@
                          M-R-1-1-P.   A pr.-Lti-,ary purpose of this review ,i@is to icl(,i-itify an-,I
                          discuss issues for the si-te visi,t on March 30-31.               Si-nce only
                          six projects have cori,.-,I!Lment and since any reduction i.n the
                          level of funding for 1-971--72 would coiicc@ival)ly ilLer the Regi,oii's
                          plans for use of committed funds, deliberation of the conti.n'Ll-
                          ation portion of the application seemed of lesser importance.
                          Staff recommended approval of the following continuation request:

                                 #46   Hi-Blood                                         $163,41-9
                                 #50   Joplin Stroke Prevention                            87,653
                                 #51   Sikeston Intensive Care                         107,796
                                 #52   Health Careers                                  100,777
                                 #55   Cameo (tumor registry)                          114,572
                                 #58   Cardioviscular Education
                                       and Eval-uation                                 11-6,570

                                                                                         $690,787

                          Staff was gc@riC:17al,ly siLisfi(@d with the first ycar's I)rc)greFs
                          of these projects.        Rc!pi7eselitiLivc@s from the Coi-iti,ntil.ng
                          Education Branch iic)tc@(I LliiL S-LTICC' the              C@-Lr(--Crs ploposa-l-
                          no longer fall-s within fit' policy and since some of the
                          activities have been undertaken by contact wi.Lli the AiV.4C
                          Division of Studcnt Affairs (with                     funds), the Region
                          rflight@ wish to consider reducing Or evc@n T)II,!Sil-l@l-ollt
                                                                                               up T) Cj 1, t
                          of this pro@ect.        Staff @.,,oncl(ij--cd        tric- CA"i,'-O project
                                        .i                                                      i
                          receiving any technical. assistance in computer




                                               -26-




              Page 2   Acting Director, RMPS
                                                                     f would also like
              from the Advanced Technology Proposal (#49).  Staf
              clarification of the statement that the objectives of project #51,
              Sikeston Intensive Care, are beina incorporated into the new proposal,'
                                                  0
                       iat Care Missouri.  Staff also recommends approval of the
              #77, Card
              core continuation request of $1,100,000, while recognzing that with
              the proposed expansion of core by $374,165 for      district offices,
              continuin- education staff and activities in Kansas City, the total
              core request will be a major issue at the site visit.
              In addition to the continuation request, the Region's fifth year budget
              includes the following
                   Cbre                                                  $.   374,165
                   Approved but Unfunded Activities                           519,208
                   Supplemental and Revised Projects                        1,703,690
                   Renewal Projects                                           274,112
                   Developmental Component                                    400,OOQ
                                                                           $5,061,962
              The issues for the site visit are in an attached memo directed to the
              members of the site visi.t team.  One issue which staff raised requires
              your specific consideration and guidance.  This issue conce@,8 the
              structure of the Regional Advisory Group and whether the ultimate
              decision-making responsibility rests with the entire three-committee
              group (Liaison Committee, Project Review Committee and Advisory Council)
              or with the Advisory Council only.  A description of the Regional
              Advisory structure is on page 2 of the attached memo.  Our questions
              are twofold:
                   1) Can the entire three-body group constitute       the RAG; 2) If not,
              what would be an acceptable arrangement?
                   With the impending appointment of both VA and CHP representatives (to
              the Project Review Committee), this question assumes greater urgency.
              The following staff members attended the meeting on February 95th:
              Ted C  Moore, Kidney Disease Branch
              Abraham Ringel, Operations Research and Systems Analysis        Branch
              Cleveland R. Chambl-i.ss, Office of Organizational Liaison
              Cecilia Conrath, Continuing Education and Training Branch
              Spero Moutsatsos, Planning and Evaluation
              Teresa Schoen, Grants Review Branch
              Dan Spain-, Regional Development Branch
              Lee Teets, Grants Manag(,,iaei-it Branch
              Charles Barnes, Regional Development Branch
              Dona liotiseal, Grants Review Branch






                                                 27-





            Pac,e 3 - Act@Liig Director, RMPS

            Rc-.coir.iiiendati.oii: Approval of the contittuaton request of $1,790,787
            for core and projects #46, 50, 51, 52, !i5 and 58.




            Don@i E. Houscal
            PLibli(-, fact Advit-,or
            CranLs Revl.c%.j Brancli



            Action-by Director

            Initials


            Date





            cc:  Dr. Pahl




                                                                   (A Privileged Communication)




                                    SUMMARY OF   REVIEW AND CONCLUSION OF
                                         APRIL 1971,REVIEW COMMITTEE


                                     MISSOURI REGIONAL MEDICAL PROGRAM
                                              RM  00009   5/71

                                                               D
                            FOR  CONSIDERATION  BY  MAY   1971 A VISORY COUNCIL


             RECO,MMENDATIO .N:   The   Committee   recommended that this application which
                        i          quests:  1)   an   expanded Core, 2) the renewal of two
                                  re
             activities,  3)   the   suppo.rt of seven Council approved but unfunded
             activities,  4)  the  implementation  of  16   new projects and 5) a developmental
             component    be partially supported as follows:  $2,.450,000 for the 05 year,
             $2,012.,OOO for the 06i and $1,825,000 for the 07 year.

             A comparison of the request and the site visit team and Committoe's
             recommendation for the 05 year is outlined below.


                                         Request               site visit               Committee

                 1.  Core                $1,474,000               $850,000               $850,000

                II4   Computer   and
                   Bioengineeking             861,000              600,000                250,000
                   Activities (ir69,
                   71072,75)

               III.  Community based
                     Activities    (#25R,,
                  36 37 38,39,43,46 50,
                  51 64,68@73,74,76,77,
                     p
                    80,81,83)               1,664,000         .120009000               1.,000,000

                 IV. Continuing     Educa-
                     tion Activities
                     (#52,55      58,67,78
                             p           31
                     79,82,26R)               663,000              400,000                350,000

                  V. Developmental
                     Component                400,000              -0-


                   TOTAL                 $5,062,ooo..!/       $2,860,000               $2,450,000

                 $1.8 million is committed support.




            Missouri RMP                                               RM 00009 5/71

                       in its deliberation the Committee accepted   the report of
                       the site visit to the Missouri Region on March 30-31, 1971.
            The site visit was a 'comprehensive one, with members of the t .eam reviewing
             eparatelv the activities in Kansas City, the  continuing  education  pr
                                                                                   ogram,
            computer and bioengineering proposals, as well as the central decision-
            maki.ng., review and administration processes in Columbia.  Two  members
            of the site visit team participated in the Committee discussion.

            The visitors reported that the Region had made progress in certain aspd'cts
            of program development since the last site visit, but that..or@anizational
            weaknesses were hampering growth in many areas.

            The Regionts goals are broadi with poorly defined intermediate objectives.
            Program has been primarily determined by a collection of projects, which
            have been submitted by interested-individual-s and aligned with Regional
            goals after the-fact, rather than stimulated on the  basis  of  Regional
            needs.  Program evaluation is geared to assessing the achievement of
            project objectives.

            While the Coordinator is well-liked, he is not  as forceful or efficient
            an administrator as he could be.  Organized at  a time when PIIP's budget
            was projected for a $200 million level, the Core staff is oriented almost
            exclusively to projects (processing applications and monitoring approved
            projects) and has attained a size out of proportion to  the  program  it
            handles.  In addition, Core staff has continued to maintain its adament
            position that proposals from sponsors in communities outside the
            University setting be,developed with little staff  assistance  in  order
            to preserve local flavor and feelings of pride.  The  team   recommended
            that the size of Core staff be reduced and that better service be
            offered to local proposers.  At the same time, the team encouraged
            the Pegion to disengage itself from the project approach reprogram
            development by seeking other sources of support, using  smaller  amounts
            of Core funds to initiate activities on a short term basis, and phasing
            out projects which are no longer appropriate or are not performing
            ad64uat6ly,

            The Missouri RMP Regional Ad vi8ory Group has a unique tripartite structure.
            While it appeared to the site visitors-to work effectivelythe decision on
            the legality of the arrangement, particularly in relation to the placement
            of VA or CHP representation, seemed more appropriate for General Counsel.
            Reviewers felt that the very nature of the RAG may have  contributed  to
            the broad @nd irrelevant  goals.  ThIe Regional Advisory Group also
            appears heavily oriented to project review, rather than to broader
            regional planning.  The review process, which includes technical
            consultants and a ranking system, appears adequate.
            Relationship with regional resources, particularly providers and
            voluntary healtbagencies, is a strong point in the Missouri program.
            The visitors were distressed that the Region seems to feel that
            consumers aIre adequately involved in program development through CHP
            representation in the advisory groups.  Medical school leadership
            is still active in the program, although the proportion of






      Aft
            Missouri RMP                           -3-;               Pm oo69 5/71

            University sponsored projects is declining.  As the grantee agency,
            it also provides fiscal and administrative support.

            The 'continuing education part of the program seemed in need of a strong
            director of continuing education on Core staff with an Advisory Committee
            to serve him.  The Coordinator should coordinate efforts of, and offer
            assistance to, project proposers by locating resources, opening lines
            of communication with the medical school and developing  models  of
            evaluation.  After discussion with project personnel, the team felt
            such a staff person would prove more effective to the  Region  than
            initiation of the Continuing Education  Coordination  project.  The
            visitors felt that some of the functions of inventory  and  teacher-
            consultant activities outlined in this proposal could then be carried
            out by contract with the UM Extension Division.

            With little assistance from Core staff the subregional  part of  the
            program has continued to be one of the stronger features  of  M@IP.
            The Kang@ City Area Planning Office has hired staff, engaged resources
            and worked as a cobrdinator-facilitator between the new medical  school  and
            the rest of the community's health system. The  COMPACT  proposal,  which
            would coordinate interbospital departmental meetings and upgrade medical
            education, resulted from these efforts. The site  visitors  found  the
            concept'of such a proposal sound and believed it should be  funded  by
            RMP for one year until the participating hospitals assumed  its  support.
            Because of the difference in approach to program development  and  the
            unique problems of the urban setting, the Kansas City Office's
            relationship with the central MRMP Core in Columbia shows 'signs
            of @strain. At the present, MRMP's relations with  Kansas  City  ate
            primarily that of fiscal agent and source of final  project  review.
            The site visitors recommended that priority be placed  on  staffing
            proposed gubregional districts and strengthening those  already  in
            operation.

            Both site visitors and Committee members had difficulty determining
            what course to follow with the computer and bioeftgineering proposals.
            Much has been invested in these activities during the past four  years  with
            reports of mixed results from previous site visitors.  The  present  team
            was pleased with the Region's progress@, and recommended reduced  support
            for one last year, but with the realization that actual marketing  and  full
            implementation of the-systems could still be two to three years away.
            They felt that the operation in Dr. Bass' office in Salem (#72) could
            prove valuable in determining the practicability of such a module in a
            solo practitioner's office, although they had reservations  about  its
            cost effectiveness.  Initiation of the automated patient history
            system field test in Cape Girardeau' was considered ap imprudent  investment
            at this time.

            The site visitors presented their funding recommendations for Comniittee's
            consideration. Committee accepted the teamts  recommendation  for  a
            reduction  o.f the Core budget to $850,000 and a reorganization of Co@e
            functions.  Implicit in the recommendations is the advice to, 1) preserve
            and strenatben the district offices, including the Kansas City Office,
            and the Program Methodology Unit, 2) add a Director  of  continuing





           Missouri RMP                              -4-                 RM00009   5/71

            education to Core staff, and 3) reduce the     Planning and  Ope-tat'ions
            staff and consolidate its functions within     the  Coordinator's   Office.
            Committee was disturbed that the Region had not learned to make
            better use  of the Program Methodology  Unit,  which  could  serve  as  a
            great resource by  supplying  data  bases  for  determination  of  Regional
                                          o  "' 11
            needs.   That the unit had t  se  .  the  Region  on  using  its  service's
            highlighted  Committee's  continuing  concern  with  MRMP's  overall   program
            development and management.

            Committee deducted  $50,000  from  the  site  visitors'  proposed  $400,000
            level for  continuing  education  activities  because  they  did  not  believe
            that new money for continued support of project #55, CAMEO, should be
            provided.  The  development  of  a  computerized  treatment  logic  system
            for patients with breast  cancer  and  colon  cancer  raised  fears  about
            diffusion and  acceptance  of  the  treatment  modalities  being  generate
            by the system.

            The $1,000,000  level  for  comniunity-based  projects  was  accepted  by
            Committee.  Although they were pleased that provider support had been
            successfully brought into l@IRIIP,,high priority should now  be  placed  on
            involvin&  consumers  in  program  development.  Needs  should  also   be
            better defined so that  such  proposals  really  meet  the  more  pressing
            health proBlems of the community.

            Committee was opposed  to  the  site  visitors'  recommendation  of  $615  000
            for  ComputerLand  bioengineering  activities.  T4hile  a  further  year's
            investment in Dr. Bassi operation ($150,000) was accepted,           Committee
            recommended that support for the other three proposals be phased
            out this year.  $100,000  was  provided  to  phase  out  these  Activitieso
            Complete termination reports  of  the  five  years  activities  should  be
            submitted to RMPS.  One reviewer raised the question of appropriateness
            of continued RMP support for computerized EKG development when commercial
            funds are now available.  In addition, be stated, most systems have not
            progressed to where  review  by  a  cardiologist  can  be  totally  supplanted
            by the computer analysis.  Reviewers also thought that Missouri s efforts
            should have been directed  to  hospitals  with  larger  volumes  of  EKG's
            than to individual physicians.

            There was agreement with  the  site  vislitor's  that  the  developmental
            component be denied since  neither  group  believed  that  tbb  Region  had
            demonstrated it was ready for or would utilize such funding in
            imaginative ways.

            In conclusion, Committee stated that  they  thought  a  site  visit  in  a
            year's time for  assistance,  as  well  as  evaluation  pupposes  would  prove
            b6loful to the Region.

            Dr, Mayer was not  present  during  the  deliberations  of  this  Region.



                                                             RNP S / GIZB
                                                             4/22/71





                          DEPAriTMPNT OF tiEALTH, EDUCATION, AND'WELFARE
                                         PUBLIC HEALTH SERVICE
                           IQEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION


              April  12, 1971



              Short Summary of Missouri    RMP Site Visit Findings, March 30-31, 1971.

         To:  Director
                gional Medical Programs Service

              Thro   Rh. Acting Deputy Director
                        Regional Medical Pr6gtAms Service

              The@site visit team consisted of:

              0. V4 Brindley, Jr., M.D., Chairman Department of General and Thoracic
                S  gery, Scott and White Clinics, Temple, Texas, and Chairman
                Of th  8'te Visit.
                       e  i
               le  6d&r M. M6Phedran, M.D., Emory University Clinic and Council
                M   et.
               ilit4m'L. Black, Ph.D., Staff of M.I.T. Lincoln Laboratory
              D.n      F.@Brayton, M.D., California      rea     oor  na or
                   Oncis DAmmann, M.D., Professor of Biomedical Engineering,
                u  ve-rsitv of VirRi6ia School of Medicine
                    job Son, M.]?., Practicing Physician, Rockford, Illinois
                r  ny     K6maioff, M.D., B6th Israel Hospital, Boston, Massachusetts.
               ill rd L. Thompson, Ph.D. Dean of General Studies Sessions and
                    et Sessions, University.Of Minnesota.
                .P,D6na H66seal, Grants Review Branch, RMPS
                r  n E. Leach, Ph.D., Continuing Education and Training Branch
              Mr.      Ray Maddox, DHEW, Region VII.
                s  Teresa Schoen, Planning and Evaluation Branch
                  bAn Spain. Regional Development Branch

                e@@ urpose of scheduling a site visit for Missouri at this stage
              in   e Regibn'8 development was to examine the new MRMP thre6-year plan--
              .a   duct@of its operational ex eri@nce since 1967 which requ6sts expanded
                p                             p
                n      at a time of reduced overall PIIP grant moftles.  This level Of
              t n   g  would support further program development in t e Kansas City
              D s  i6t@ n8,in smaller regional centers, renewal of several computer/
                oo @9-inee ihg R & D attivities,@,and A substantial developmental
                       nt.@ Projects presented in this plan can be grouped in four
                                                                         i uing education,
              mai  plagses-  Orogram guidahce,-conmunity service, cont n
                d      0 t6r/bloengineerihg activities.
              an   Om  u@
                       of the complex character of the Region, the sitevisit WAS
              Cl@Iv d i to four parts.  On Match 29th, the entire team met in
               a  as City for an evening btiefing and strategy session. On March
              i6t   the@team divided into groups.




           Page 2 - Director, eMPS

                 Team I (,D7-. Brindley, Dr. Brayton, Miss Houseal and  Mr.  Maddox)
           traveled to Columbia to review the region's central decision-making
           processes  core operations, and relationships with   other statewide
           agencies and institutions.
                 Team II (Drs. Thompson and  Leach) accompanied  the  fiIrst  team  to
           Columbia and met that afternoon and the  following  morning  with  various
           regional representatives involved with  the  Region's  continuing  education
           activities.

                 Team III (Drs. Dammann, Black and Komaroff) flew to.Salem, Missouri,
           to review the computer/bioengineering components which had been assembled
           and field tested in a local physician  s office. They also  met  with  the
           pto4ect proposers in Columbia on the following morning.
              i

                 Team IV (Dr. McPhedran, Dr. Johnson, Mr. Spainand Miss Schoen)
           remained in that area to discuss RMP  developments  there  -  particularly
           relationships with the new medical school and linkages with providers And
           other health-telated a 6ncies.
                                  9

           The entire site visit team convened in Columbia on  the  evening  of  the
           30th for a review of the first day and to  discuss  changes  in  strategy.
           Toward's the end of the second day, time was provided  for  an  executive
           session to discuss overall findings and recommendations and then to
           pr6vid  feedback to the Region before adjournment.

             il6 the structure of this site visit was more  complex  than  most,  the
           Sir a d- diversity of the Missouri program  necessitated  a  review  similar
           to that conducted at the last visit in Ottober 1969.

           The site visit team was generally pleased with the Region'sprogress since
           that visit but stated that serious organizational weaknesses were hampering
           growth in many areas.

           The Region's. goals and objectives are vague  and broad. They  do  not  seem
           to have changed much since the beginning of   the program. There  was  not
           much evidence that the Region had attempted   to incorporate HEW or  HSMHA
           6bi6ctives or priorities within their own.    Program has  been  primarily
           determined by a collection of projects,. which have been submitted by
           interested individuals and aligned with Regional  goals  after  the  fact,
            atber than stimiated on the basis  of  regional  needs.  Evaluation,  then,
            as beoomea matter of looking at  the  achievement  of  project  objectives.

            he orgah@iiational effectiveness of Core. was seriously questioned  by  the
           site visitors. While Dr. Rikli,  the  Coordinator  is  well  liked  around
           the Region, he is not as forceful An administrator  as  he  could  be.  With
           SI man project activities, a large core  staff,  his  involvement  with  the
             tension Division and other 'University matters, be is  spread  so  thin
           t at his control of the program suffers.

            ore staff .,itself has several strengths and  weaknesses.  The  strengths
           are the Kan@sas City operation (to @e discussed below), the other subregioaal




           Page 3 - Director,  MPS
           offices whichIare engendering provider support  at the community  level,
           and the Program Methodology Unit, which could serve as a  great  resource
           in building program definition by supplying a database.

           The chief weakness is that Core is presently organized  around  projects
           first processing project applications and then monitoring  the  approve
           proposals.  The site visitors further determined that the number of staff
           hired to perform these tasks was out of proportion with  the  total  size
           of the program and should be reduced. A further criticism  was  that  the
           planning section had hot offered enough assistance to  project  proposers,
           particularly to those outside the university setting, in project development.
           Core staff has not vered from last year's adament position that
           proposals be written withoutcore staff assistance in order  to  preserve
           local flavor and feelings. of pride. The team., however, thought  that
           better service could be offered to these local proposers without
           injuring their integrity. In fact, the overall  program  could  benefit
           from a more aggressive approach to proposer assistance - from recommending
           tb6 deletion of aspects of projects which are not appropriate  for  RMP
           support to helping to find other sources of funding.  In a time of
           lessening availability of funds from the national level, Core's persistence
           in turning out a large number of projects seemed anachronistic.  The site
           Visitors believed that the central Core could profit the  Kansas  City
           operation's example of using smaller amounts of Core  funds  imaginatively
           to@initiate activities on a short term basis until others  could  support
           them. Core also seemed to become so committed to  funded  projects  that
           they rarely modified weak proposals and had difficulty in  phasing  out
           those which were not performing adequately.  The site visitors felt
           that it should not take three years to phase out those projects.

           The Regional Advisory Group also appeared heavily oriented  to  project
           review.  While data for planning on a Region-wid6 basis has been collected
           by Core staff, there was little evidence that the RAG has used this
           information to assess need and recommend the initiation  of  appropriate
           program activities  Little thought had been given to the use of the
           developmental component, other than to stimulate or start  up  project
           activity.
           The Missouri Regional Advisory Group has a uniqud structure  among  RMP'so
           It includes,three bodies-- the Liaison Committee, the  Project  Review
           Committee, and the Advisory Council. The membership  and  the  structure
           are described in the staff summary of the  application.  Arranged  this
           way in order to allay fears of University domination of  the  program,
           the Regional Advisory Croup as a whole performs effectively.  The problem
           of which group the CHP and VA representative should belong to  and  the
           legality of such a structure, particularly when projects  disapproved  by
           the Liaison and Project Review Committees are then approved by the
           Advisory Council, the site visitors believed, should be settled at
           the General Counsel's level.
           The review process, which is the responsibility of the RAG,  is  adequate,
           It provides for an assessment of the proposal's relation  to  activities
           supported by other agencies in the  Region, technical review (with
           occasional site visits) and a determination of its place in  the  overall




            Page 4  Director,  APS
            RMP nrogram. 'Two of the three Igroups use a numerical rating, although the
            criteria on which the rating is based has not-been  formalized  on  paper.
            CHP comment has been instituted.

            Relationships with the regional resources is a strong point  in the
            Missouri program.  The program seems to have the support of  the   Medical
            Society and many practicing physicians, the doctors of osteopathy,
            nurses, allied health professionals, and hospital administrators.,
            Voluntary agen6ies' representatives spoke well of MRMP, as did those from
            CHP. Although the Region seems to  feel  that  consumers  were  adequately
            involved through CHP, they are not generally well  involved  in  program
            development. Medical school leadership is still  active  in  the  program,
            although the proportion of  University-sponsored  projects  is  declining.
            As the grantee agency, it Also provides fiscal and administrative support.
            Program as stated earlier, is a composite of  projects. Two  parts  of  the
            site visit team reviewed particular parts of the program-continuing education
            and computer,fbioebgineering - in great depth.

            Continuing Education
            Drs. Thompson and Leach spent a great part of their  time  discussing  the
            Continuing Education - Coordination Project and  the  proposed  Appointment
            of a Core director of continuing education with  the  Regional  tepresenta-
            tivbs. The visitors agreed that  the  inventory  and  teacher"consultant
            activities described in the twice disapproved  and  revised  Continuing
            Education Coordination Project would possibly serve  useful  functions  in
            identifying continuing education needs of  various  health  professions
            around the Region. Discussion with directors  of  ongoing  and  proposed
            projects brought the visitors to the realization, however,  that  what  is
            most needed is a strong director of continuing  education  on.Core  staff,
            who could coordinate efforts of, and offer assistance to, project
            pro osors by locating resources, opening lines  of  communication  with
              p
            the medical school and developing models of evaluation.  There was
            significant concern among University-affiliated staff that  such  a  person
            ould not involve MRMP Coro in, or sponsor through Core,operational
            activities. This would, in the opinion of  the  site  visitors,  weaken
            the ability of such a person in assuming a strong role with the Continuing
            Education Coordination project or with--6ther  projects.  The  site  visit
            team recommended strongly that the Coro Director position  be  funded  and
            that the functions of the Continuing Education Coordination Project
            be given to the Core Director of,Continuing Education.  An Advisory
            Committee named in the proposal should also be selected  and  serve  the
            Core Director. Core might then contract  with  the  Extension  Division
            for some of the functions outlined in the inventory and teacher-consultaftt
            activities.

            Projects designated by the Region as  primarily  continuing  education-
            oriented were,also reviewed. By and large.,  they  serve  the.purposes  of
            an individual institution or community, rather  than  the  Rbgion's  needs
            in continuing education or manpower development as expressed in an
            overall plan.





           Page 5 - Director, tIMPS

           Computer/Bioengineering

           The visitors who reviewed this part of the program  were  pleased  with
           the progress since the last visit. The site  visitors  traveled  to  Salem
           to visit the proposal which had assembled and field  tested  the  computer
           and bioengineering components in a solo practi.ti.oner's office in  Salem,
           Missouri. While Dr. Bass' exceptional  interest  and  enthusiasm  were
           obvious assets, the visitors had reservations about  the  cost  benefit
           of establishing this comprehensive system in  a  solo  practition&r's
           office located in such a small community. T-lith the  commitment  of
           Dr. Bass, the practicing physician in Salem, the  cooperation  of  the
           University-based project personnel, the system is  operational  and  being
           tested in his office on two to three patients a day-  The system includes
           the automated patient history acquisition system, automated EKC-., biochemical
           screening, fact bank and an on-line  radiology  reporting  system.  There
           is still,mucb work to be done with  consolidating  design,  software,
           and.hardware changes, and marketing of ti-ie total system may be  two or three
           years away.

           With a change in project direction, the automated  EKG  proposal  has
           overcame many of the obstacles, including reducing the cost per EKG, facing
           it in the-fall of 1969. Several major weaknesses  still  neeg  to  be
           corrected before full implementation.  Since developments are occbtiftg 80
           rapidly, however, the site visitors recommended looking at these components
           in another year to determine future funding.

           The site visit team believed that the Fact Bank should  be  supported  by
           outside sources after this year and that the  Cape  Girardeau  experiment
           not be started at this time.


          O@mmu-nitv--based ProgrAmsi including Kansas
              I

           After hearing from some physicians-in smaller  Communities  around  the
           state and vi8itina the Kansas City subregional program, the site visitors
           concluded that the activities in these areas continue to be  some  of  the
           more dynamic aspects of the program.  The Kansas City Area Planning Office
           has made great progress since the last-site visit---staff  has  been  hire
           resources found and program activities initiated.

           Located in the only major metropolitan area in MRMP,  the  Kansas  City
           Area Planning Office has seen its tole and  problems  as  distinctly
           different from those of the Region as a whole.  In  the  "Hospital  Hill"
           section particularly, kansas City  has  a  considerable  concentration
           of health resources and ongoing activities, including:  a developing,
          communitv-oriented Medical School, a large  number'of  community  and
           ljniversity-affiliated hospitals, developing Model Cities and OEO clinics
           and health centers, a burgeoning CHP "b"  agency,  supportive  civic
           leadership and professional societies  a variety of allied health training
           resources and continuing education programs  and  a  new,  nonprofit
           technical assistance organization    the Health  Resources  Institute.





              Page 6 - Directu- RMPS

              With such resources available, the KC Area Planning Office has Concentrated
              on a cobrdinator-facilitator role, particularly focusing  on  activities
              related to Medical School development as part of the  total  community
              health sy'steml(i.e., assisting in establishment of a Community Wide
              Residency to provide programmed clinical experience for medical students
              and residents in community hospital, health centers and the  KC  Ceneral
              Hospital docent units.)
              Four projects have been developed in the area -- the terminating Programmed
              Comprehensive Cardiovascular Care Pro'oct, the ongoing project Hi. Bloodi
              the proposed Improvement of Pharmaceutical Services  and  COMPACT.  The
              Site Visit team considered these to be basically sound concepts and well
              developed. But despite encouragement from MP-IIP to channel its  efforts
              into further projects, the Kansas City Office prefers to  maintain  its
              current role, which site visitors agreed was an  appropriate  one.  This
              independence, a probable source of tension within  MRMP,  nevertheless
              seems to have been accepted by the Region in view of the areals peculiarly
              urban problems. Besides general concurrence of Kansas  City  goals  with
              very broad Regional oals, Y@RMP's relations with Kansas City  are  now
                                  9
              primarily that of fiscal agent And source of final project review.

              Conclusions and Funding Recommendations

              The site visit team concluded that the Missouri RMP is making progress,
              particularly in subregional development, which should continue  to  be
              fostered.  Serious organizational problems, 4n overwhelming project.
              orientation to the Accom lish@ent of program, a nd lack of full assistance
              for those developing proposals at the community level disturbed the
              site visit team and influenced their determination of funding
              recommendations.

              For their next three years, the Region has req@ested:

                            05                  06                     07

                     $5,061,962              $45310,940            $3,511.,564

              The fftli              includes:
                   1    'year request

                   $1,500,000 for Core
                     600,000 for continuing education activi
                     900,000 for computer and bioengirioeting proposals
                    1,700,000 forIcomniuftity-bas@d activities
                     400,000 for a developmental component

                 $1,800.,OOO of the $5,100,000 request is committed support.
              The site visitor,s.recommended a $2,865,000 level for the 05 year  which
              includes:

                  @850,000 for Core with the strong suggestion that  the  subregional
              or district offices, including the Kansas City Office, and  the  Program
              Metbodology'Unit be nerserved and strengthened. 'llie Core Director  of





            Page 7 - Director, -,MPS

            Continuiftk tducation should be added to staff.     However, it  was recommended
            that the Planning and Operations staff be reduced and consolidated with
            the Coordin'ator's Office.

                  $400, 1000 for continuing and new continuing education activities.
            This amount includes reduced funding for projects l@26R. one-year funding
            for #78, full funding for #79, no funds for #82 and #67 and suggestions
            for inyproving and phasing out ongoing activities for which outside support
            now exists or RMP support is no longer appropriate.

                  $615,000 for one year only for computer and bioengineering
            proposals.

                  $1,000,000 for community-based projects with advice to the
            Region to continue to emphasize this vital part of the program.

                  No funds for the developmental component, since the site visitors
            did not believe the Region has demonstrated that it was ready for or
            would utilize such funding in imaginative ways.
            'A summary of the three years funding recommendation foll-o@@ys:

                        05                        06                   07

                  $29865,000                  $2;067,000            $1,825,000




                                                       Dona Houseal
                                                       Public -Health Advisor
                                                       Crants Review Branch










                                   REGIONAL MEDICAL PROGRAMS SERVICE
                     SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION
                                       (A Privileged Communication)

            MOUNTAIN  STATES (WICHE) REGIONAL MEDICAL PROGRAM        RM 00032 5/71
            525  West Jefferson                                      April 1971 Review Committee
            Boise, Idaho  83702

            PROCRAM COORDINATOR:  Kevin P. Bunnell, Ed.D.

            This region is currently funded at $1,873,974 direct costs ($365,146 ind.)
            for its third operational year, ending February 28, 1971.  The Anniversary
            date has been changed to June I at the request of the region, with
            additional funds ($64,776  ) being required for the 3-month extension,
            based on the present rate of expenditure.  It should be noted that
            varying indirect costs for the region represent an average  indirect
            rate of 19.5 %, of the total direct cost award.

            The Triennium application under review is composed of:

                         I. - A Developmental Component
                        II. - The Continuation of Core and 11 ongoing activities
                       III. - Proposals for 6 new projects
                        IV. - The renewal of 1 activity

            The region requests $2,449,940  for  its  fourth  year  of  operation,
            @,2,617,542 for the fifth, and $2,486,328 for the sixth.  A chatt identi.-
            fying the components for each of the three years is included in this
            summary.


            A site visit is scheduled for March 8-9, 1971, and a preliminary staff
            review of the application has identified several issues for the visiting
            team Is consideration and assessment.  These are also a part of this
            summary.

            In the general reduction of funding levels for all regions,MS/RMP (WICHE)
            received a committed direct cost  level  for  FY  1971  of  $1,474,765
            (from $1,611,764).

                                    FUNDINC HISTORY (direct cost only)


            PIANNING STAGE


                Grant Year                    Period                     Funded

                     01                 II/l/66 - 10/31/67                $698,845
                     02                 II/l/67 - 12/31/68                 884,034


            OPERA'I'f.ONAI, f'ROGRAM


                     01                  3/l/68 - 2/28/69
                                     (overlaps with planning stage)and
                     01(increase)     supports I operational activity and
                                      2 months Core                       346,159





           MOUNTAIN STATES RMP                     2                  RM  00032  5/71

           OPERATIONAL PROGRAMS (cont.)

                   02                        3/l/69 - 2/28/70          $1,562,967
                   03A2                      3/l/70 - 2/28/71           1,873,974



           [ITSTORY OF REGIONAL DEVELOPMENT

           Development of the Mountain  States  Regional  Medical  Program  was  based
           on an extensive analysis of the area's  health  needs,  and  methods  to
           meet those needs were carried out during its planning phase.

           @@.IICHE (@.letern Interstate Commission for Iiigher Education), a compacting
           organization of 13 western states,  had  been  interested  and  active  in
           developing medical education programs  in  the  western  states  that  did
           not have medical schools.  The TDICHE Advisory Council on Medical Education
           recommended that the four states be designated as a Region for a
           Regional Medical Program under P.L.  89-239,  and  that  WICHE  apply  for
           a planning grant with objectives of upgrading and improving the existing
           facilities at community levels to  provide  optimum  patient  care  in
           heart disease, cancer and stroke.

           INIICHE received a planning grant from the  Division  of  Regional  Medical
           Program for a two-year program, beginning November 1, 1966.       T4ithin
           a relatively short time,  four  full-time  and  six  part-time  physicians
           formed the nucleus of a  professional  staff.  A  regional  office  was
           opened in Boise, Idaho, to  coordinate  activities  in  the  four-state
           area. State field offices were  opened  in  Great  Falls  and  Missoula,
           Montana; Boise , Idaho; Cheyenne, Wyoming; and Las Vegas and Reno, Nevada.
           @,.IICHE headquarters office in Boulder, Colorado handles  the  fiscal
           Management.
           Preliminary analysis of the surveys made  under  the  auspices  of  the
           planning grant indicated a,critical  need  for  coronary  care  training
           and cancer diagnostic  and  treatment  centers.  The  establishment  of
           the Missoula Intensive  Coronary  Care  Training  Program  for  physicians
           and nurses, and the Tumor Institute in  Boise,  served  as  first  steps
           in meeting the goal to  develop  new  clinical  resources  and  educational
           programs.  The survey findings also indicated the health professional's
           desire to increase his capabilities  to  care  for  patients  and  provided
           the impetus to develop programs focused to meet local needs.
           ';he regionts first operational si.te visit took place in February 1968 and
           its second in October 1968.  It was clear that the regional council of
           State.Directors was becoming more  effective  as  an  integrating  and
           planning activity.  As state programs evolved, a network of stibregional
           offices developed in Las  Vegas,  Reno,  Boise,  Pocatello,  Cheyenne,
           Buffalo, ('@reat Falls and Missoula. '['I)e site teams believed  that  this
           Represented the minimum  organization  mandatory  for  continued  health
           planning and the development  Of  further  operational  programs  for  the
           region.





             MOUNTAIN STATES RMP                 - 3 -              RM  00032  5/71



             G1710GRAPHY AND DEMOGRAPHY


             The Mountain States (WICHE)  Regional  Medical  Programs  includes  the
             four-state area of 435,643  square  miles  of  Wyoming,  Nevada,  Montana
             and Idaho with a total population  (enumerated  in  1970  Census)  of
             2,230,000 persons. The population in the four states increased about
             14'/,, compared with the 1960 Census (and notably Nevada).  Keith  the
             exception of the few  larger  cities,  the  rural  population  represents
             nearly 50'/. of the total.

             FACILITIES AND RESOURCES

             In the last few years there has been a shift in resources and facilities
             with an increase in training facilities and hospital capacity.

             Nevada has a developing 2-year medical school, with opening scheduled
             for 1972.  The number of active practicing physicians and osteopaths
             totals 2,100:  647 in Idaho, 696 in Montana, 451 in Nevada and 306 in
             Wyoming. The ratio of physicians  and  D.O.'s  averages  about  94  per
             100,000 population ranging,from: 89  in  Idabolto  102  in  Nevada;  a
             ratio of 98 for Montana and 94 in Wyoming.  The latest data regarding
             graduate nurses indicates a  total  of  about  9,600  registered  nurses.
             Of these 6,700 (,almost 70'/.) are reportg5d to be actively  employed  in
             nursing. They  are  located  as  follows:  Idaho  1,954,  Montana  2,483,
             Nevada 1,060, Wyoming 1,209. @'The increase  since  1962  is  about  250.
             The number of schools Al-ch are training,  allied  health  staff  has
             increased some.  There are a total of 14 schools of medical technology
             (all hospital affiliated) in the region Vftb 6 in Idaho, 4 in Montana,
             3 in Nevada And I in Wyoming.  There  are  22  schools  which  provide
             training for radiologic technicians:  7 in Idaho, 6 in Montana,
             7 in Nevada and 2 in Wyoming.  Two  in  Nevada  are  University  based.

             The regionis 15 professional nursing  schools,  13  of  them  college  or
             university affiliated are:  4  in  Idaho,  each  college  affiliated;
             6 in Montana, 4 of them college  affiliated;  2  University  based  in
             Nevada and 3 college  affiliated  in  Wyoming.  30  licensed  practical
             nurse training schools  are  also  operated.  Many  are  school  district
             or college affiliated as follows:  15 in Idaho, 5 in Montana,
             2 in Wyoming and 8 in Neva a.

             Community general hospitals have increased in number and in bed capacity,
             compared with 5 years ago.  There  are  148  short  term  non-Federal
             hospitals with a capacity of 10,496 beds:     Idaho has 48 and 2,879 beds;
             Montana has 56 and 3,841 beds; Nevada has 17 and 1,951 beds and Wyoming
             27 with 1,825 beds.  There are also 4 long-term special general
             hospitals with 963 beds and 5 V.A.  general  hospitals  with  a  total
             capacity of 826 beds.




         14OUNiAIN STATES RMP                    - 4              RM 00032@5/71



         l@f,-,(;TONAJ, ADVT@,ORY (;ROUP

         The necessity for streamlining the operational structure of MS/RMP
         promted a regoranization of the RAG, retaining the geographic represents-,
         tion while reducing the total number of  members.  Geographic  coverage,
         has been broadened and Task Forces and committee s have been  increased.

         The Core staff and the RAG working together developed  specific  feasible
         and long-range objectives for the MS/RMP Triennium.  Utilizing '
         questionnaires to each member, critiques and comments  were  obtained
         to assist in shaping the final draft, which was presented to the
         entire Group for consideration and approval.

         The broad regional objectives established by RAG represents expansion
         of ongoing activities which are focused on four specific targets:
         1) Sub-regional centers for Continuing Education; 2)  Health  Centers
         for Residents; 3) Stimulating Health Manpower development; and
         4) Specilized Centers Development. A system  for  setting  priorities
         for activities within these objectives is currently  under  development.

         The Mountain States RMP is providing expertise and resource personnel
         for health planning in each of the four Model  ,Cities within the  region.
         Core as well as RAG representatives have leading roles in  each  state
         and areai The present RAG includes two CHP  representatives  as  well
         as one appointee from the Veterans Administration.

         REGIO,NAL GOALS AND OBJECTIVES

         The re gion has identified four goals which are expected to be  areas  of
         major program emphasis for the next Triennium.   These may change in  the
         event of unexpected circumstances, but long-range planning  (3  year)
         reflects the following overall objectives:
         Sub-regional Centers for Con@tinuing Education -  These will be
         associated with a community hospital and, when possible,  an  educational
         institution, have a local Advisory Council consisting of  consumers  from
         a variety of health occupations.  Continuing health education opportunities,
         through a sub-regional faculty of skilled practitioners who  are  also
         skilled teachers, will develop a mechanism for  continual  evaluation
         of continuing health education needs.  These efforts will be coordinated
         with Public nealth Departments, voluntary health  groups,  hospitals,
         and other organizations in developing programs.

         Health Services for Rural Residents -  The region hopes to improve
         the quality of, and accessibility to, basic health care  for  citizens
         of the region, with emphasis on those living in rural areas.  This
         will be accomplished through the use of new types of manpower, new
         organizational patterns, service-oriented systems, and new equipment.
         Plans are underway for development of basic health care  teams  having






          MOUNTAIN STATES RMP                  - 5 -                RM  00032   5/71



          an appropriate combination of  health  occupations,  with  new  kinds  of
          manpower to  serve  rural  areas,e.g.,Medex,  medical  referral  specialists,
          nurse clinicians, etc.  The  region  is  also  planning  and  developing
          s(ib-regional health centers, transportation mechanisms for rural
          patients, demonstrations of use of remote TV for diagnosis and
          prescription.  Educational opportunities for indigenous "health educators"
          such as health aides, and Indian health advisors, are also being explored.

          Stimulate Health Manpower Development - MS/RMP hopes to stimulate
          educational institutions,  state  systems  of  higher  education,  hospitals,
          and professional associations to  plan  and  develop  new  programs  and
          improve programs for in-service education.  This will be done through the
          strengthening and  expanding  existing  programs,  and  encouraging  planning
          and development of programs for new health careers.  Also, attention
          will be gi.ven to the development of basic sciences education and other
          clinical training for medical education and students of health occupations.
          Ir-service education opportunities that will improve careers and
          facilitate transfer into new careers will be developed.

          S2ecialized Centers Development -  Through educational programs MS/RMP
          will assist in development of specialized centers located in selected
          urban centers within reasonable  access  of  urban  and  rural  residents
          as model or demonstrations for diagnosis, consultation and education
          related to major diseases and disorders.

          The 14AMI Program (Washington, Alaska, Montana, Idaho) is under-way to
          provide medical education extending  beyond  the  campus  of  the  University
          of Washington at Seattle to communities  of  this  region  in  Idaho  and
          Montana.


          Sub-regional centers with the four states have been identified in
          twenty strategic areas having a critical mass of population, patients
          and practitioners.  These new centers, now in various stages of
          implementation, will provide an organizational base for  the  coordinated
          activities throughout the region.

          Ic"laho has established seven SLib-regional centers with part-time Coordinators,
          each located in communities served by a university or community college.

          Montana has designated five RMP Districts, with Medical- Education
          Coordinators thus far for Districts one (Western Montana) and  three
          (Eastern Montana). A Coordinator for each of the years 1972, '73, '74,
          is a long-range projection for the remaining three Districts.

          Nevada has appointed community Coordinators in Elko and Ely,  and  a
          third is proposed for Carson City.  MS/RMP is working with the Nevada
          IUniversity System in its development of a two-year medical- school in Reno.

          Wyoming is developing Educational Processors (medical  educators  for
             Ik @ospitals) through special seminars.




           MOUNTAIN STATES RMP                       - 6              RM, 00032  5/71


           (,ORE @J'AFF ACTIVITIES

           Core gtaff consists  of 34.92 full-time  equivalents located in the
           regional and four state sub-regional offices.
           t4o significant changes in organization or structure  have  been  made
           during the past  grant  period.  Sub-tegional  community  education
           coordinators on both a voluntary and a  part-time  basis  were  recruited.
           A full-time person with training in  the  applied  behavioral  sciences
           was employed at the regional office level  to  coordinate  planning  '
           and evaluation efforts. The  position  of  Coordinator  of  Operations
           Programs was abolished and expanded and these duties were assumed by
           the Deputy Regional Director.
           l,lith the emergence of a medical school in Nevada, discussions are
           expected during the upcoming Triennium to explore an orderly transition
           leading to an independent Nevada  Regional  Medical  Program.  It  will
           probably be affiliated with the University of Nevada.
           With the upcoming Triennium, Core staff will assume responsibilities
           for administering Project #5 - The  Montana  Continuing  Education  for
           Health Professionals. This will be  a  step  in  systematizing  the
           development of sub-regional centers for continuing education.

           The facilitation for planning, development, and inter-relatedness
           of all operational projects will continue to be  a  Core  staff  activity,
           which will provide leadership for activities proposed,for the
           triennium.  Other activities will include the development of     an
           explicit priorities system, a refined reporting system.which    is valid
           and of immediate use in making decisions,to provide continuous recording
           and monitoring of program impact. Also,  the  region  is  thinking  of
           conjoint Core staff and efforts directed  toward  the  development  of
           more refined program objectives in terms of specific individual staff
           assignments.
           Core staff will also be responsible for planning  for  the  use  of
           developmental funds in order to assist in the transition, a heavy
           emphasis on continuing education to other forms of "systems intervention."
           @IS/RMP will not abandon continuing education efforts,  but  the  strategy
           o,@ continuing education will aim toward community-based systems changes
           a@
            lid improved inter-professional, and inter-organizational effectiveness.

           There are four active Model Cities in the region  and  members  of  the
           Core staff in the Idaho' sub-region have participated in the Planning
           a,-id Advisory Committees in the development of the Model Cities
           program in Boise. An educational  specialist  on  Wyoming  Core  staff
           is Chairman of the Health Section Advisory Group  for  a  Model  Cities
           program in that state.  A staff member of the Montana Division
           serves on a state-wide coordinating committee  for  the  two  Model
           Cities in that state.





           MOUNTAIN STATES RMP                      - 7 -            RM  00032-5/71



           TtiE REVIEW PROCESS


           The review process of the  MS/RMP  is  closely  coordinated  with  project
           development.  Survey data and inventories of resources within the region
           are utilized in generating  and  developing  ideas,  which  are  responsive
           to regional objectives, as  well  as  regional  and  national  priorities.

           New by-laws,.have been adapted for an ad  hoc  Technical  Review  Panel.
           These provide critical review by three experts outside the region
           which are appointed by the  Regional  Director  in  consultation  with  the
           RAG Chairman.


           'ti@.ile there is no formal mechanism for project review with the CIIP agencies,
           mi-tual memberships of executive and advisory boards with..RMP Core staff
           provide for an interchange of information.


           EVALUATION


           With the employment of a  full-time  person  with  training  and  experience
           in applied behavioral science on  the  Core  staff,  a  systematic  program
           evaluation method has been developed, computerized and implemented
           in December 1970.  It includes correlated information from: (1) a
           common registration form; (2) a multi-dimensional, objective and
           open-ended "analysis and satisfaction" form for participants; (3)      s,ta'"-
           dardized faculty and observer information; (4) an attitudinal        '   'f
           assessment of participants; and (5) administrative and other descriptive
           information.

           A major criterion in the evaluation system is that it must res'kLi  t
           in usable, useful and  used  information  for  planning  and  organizational
           growth.

           Simultaneously, a more extensive  system  of  program  evaluation  takes
           place through staff conferences,  consultations  with  RAG  members  and
           involvement of grassroots health providers.

           In addition, each operational  project  contains  a  provision  for  consul-
           tation on the technical  aspect  of  systematic  project  evaluation,  based
           on the principle that  evaluation,  particularly  at  the  regional  level,
           should be an integral part of  the  initial  development  of  proposals.

           Work is also underway on  the  development  of  standardized  methods  for
           evaluation of application of learning in the existing Continuing Education
           Projects.  Two training sessions have been held by MS/RMP Core and
           operational staff to stress  technical  aspects  of  evaluation  and  other
           working  conferences  for  staff  are  scheduled.  Another   p@ n  of  the
           evaluation activity has been  the  initiation  of  several  sh6
                                                                         I
                                                                         t
           into questions of concern to program functioning.                        -4,,,





                                                - 8               RM 00032  5/71
           MC)UNTAIN STATES RMP



           DEVELOFMENTAL COMPONENT
           The stated purpose of the request of $71,000 is for "developmental
           activities to pursue practical goals oriented approaches to.meet
           emerging needs and opportunities identified by mission-oriented
           task forces and MS/@P staff."
           The provision of developmental funds will increase the region's'
           capability to improve communication and planning and to study and
           redefine emerging health needs at the local level.  MS/RMP hopes
           to explore pilot activities in response to community needs,
           moving with flexibility and coordination into appropriate programs
           to strengthen existing capabilities to find effective and  efficient
           ways to improve health service.  This will also  expedite exploratory-
           activities while local resources are mobilized for self-support.
           in recognition of.a change in national direction, the MS/RMP is
           making an effort to meet the newly established priorities.  The
           policy of i4S/RMP Regional Advisory Group establishing priorities,
           and allocating and authorizing funds will continue with the award
           of developmental funds.
           .The review procelss for developmental proposals will be the same as
           for operational.projects with' proposals submitted quarterly to RAG
           members to permit critical review of documents prior to regular
           meetings.  Technical review panels will evaluate proposals as to
           feasibility  and potential for implementation.
           The region is in the process of developing criteria such as those
           used by the Michigan RMP and the Washington/Alaska RMP for reviewing
           proposals to determine priorities.  Areas of concern will include
           appropriateness, probability of success, workable relationship,
           evaluation mechanism, contractional arrangements, potential for
           development, commitment for continuation after RMP funds have expired,
           and cost-sharing possibilities.
           The region submits a list of activities which they  consider  having
           a potential for developmental funds;  (1) a pilot program for  .
           intensive infant care unit in selected hospitals; (2) development
           of Health Maintenance Organizations; (3) stimulation  of  cooperative
           arrangements between federal, state and local authorities to improve
           emergency transportation services; (4) introduction of  new  patterns
           of health services; (5) interregional cooperation  and  programs  for
           development of kidney disease control and dialysis centers; (6)
           development of radiology and laboratory proficiency; (7) study of
           the feasibility of a three phase program for diabetics. Fourth  Year
           OPERATIOINIAL PROJECTS                                         St
                                                                     $148,582
           Project #2R - Intensive Coronarv Care Training - A  slight  increase
           in funds is requested for the next (01) period of the Triennium,





          MOUNTAIN STATE RMP                    - 9 -           RM 00032 5/71


          after which time it is anticipated that the project will be transferred
          to the University of Montana and Montana State University for continuation.
          The training center was established at St. Patrick's Hospital in
          Missoula, Montana and has served as a prototype for the development
          of similar units and programs in other areas of the region.

          The Pro-jecti-,; considered successful, quite popular and has received
          excellent support of all participating institutions.  Accomplishments
          of the program have made significant impact on this region with i-mproved
          coronary care becoming available to an increased number of citizens.
          Management methods have been improved and interest continues high
          in participating hospitals. This has resulted in excellent cooperation
          with the University of Washington, the University of Montana, Montana
          State University School of Nursing and the five regional hospitals
          providing supervised bed-side experience.

          In addition to the existing program for training of physicians and
          nurses, two new programs are planned - one in ECG monitoring for
          anesthiologists and the other affording short preceptorships to
          provide tutorial experience for practicing physicians.

                                                                        Requested
                                                                       Fourth Year


          t'roject # 3R- Mountain States Tumor Institute    The region  is  requesting
   0      three additional years support or support for the project's third,
          fourth and fifth periods. The region feels  that  continuation  for  another
          full three years is imperative to ftillyimplement all aspects of the
          program and to establish its efficacy through appropriately evaluated
          mechanism of a regional cancer diagnostic and educational center.
          The Institute, which is a total cancer therapy center, constructed by
          St. Luke's Hospital in Boise uses a multi-disciplinary approach to
          patient treatment with an added component of education.  It is the
          first of its kind in the region if not in the entire West.  The MSTI,
          including land, building and equipment, is provided by St. Luke's Hospital,
          and is a fully incorporated subsidiary of St. Luke's Hospital  and  Ntirse's
          Training School.  The same Board of Directors governs both institutions.
          In addition, a policy and planning council with delegated responsibilities
          fi)r MSTI has been established.
          A Nurse Coordinator was employed on a part-time basis during  the  02  grant
          year, and a full-time Nurse Educator, a dosimetrist and an additional
          full-time radiotherapist are also requested.


                   Fifth Year: $207,172                Sixth Year:  $207,172





        MOUNTAIN STATE RMP                         10             Rm  00032  5/71

                                                                         Requested
                                                                        Fourth Year
                                                                        $76.177
                                          Education for ll(,@aitli Ilrofeqslonals
        Project l@5 - Montana Continuin@, ],,          -
        One additional year is requested(fourth period) although three,
                                                                   ed over th
        additional Medical Education Coordinators are to be add,             e
        next three year period.
        Program activities will be expanded by responding to unfilled requests.
        Twenty-three programs for 18 disciplines are already scheduled through.September
        of 1971, and at least 10 additional programs are in-the planning stage
        two of which will be for two additional categories of health professionals.

        Groundwork is being laid to insure the orderly transition of this
        project to a self-supporting status.     Some  supporting   contributions
        already are being made by health professional organizations in the
        region.
        Project. #6 - Rocky Mountain States Cooperative Tumor         str  -  One
        additional year of support is requested with a slight increase in
        funds largely for personnel for the four state area.      This cooperative
        registry, which is patient-physician  oriented,  is  designed  to  be  of
        value to the practicing physician in insuring him patient data and
        systematic follow-up.    The registry involves all of the four states,and
        in addition, the Intermountain and Colorado/Wyoming RNIPS.  While
        progress has varied from state to state,  three  of  the  four  now  have
        functioning Cancer Coordinating Committees.      Some hospitals  are  not
        participating as yet, but it is expected that the majority will join
        during the next  year.  All  registries  have  participated  in  advisory
        committee meetings of the Rocky Mountain States Cooperat ve Tumor
        Registry and registry secretaries have attended training sessions
        in Salt Lake City.
        The means to continue these activities after June 1, 1972       is  under
        active investigation.  The Montana State Department of Health is
        seeking legislative authorization and funds to continue their portion
        O@ the program when it terminates.     The State Medical Societv of
        ,@lloming is actively encouraging its state to continue participation.
         Project #7 - Continuing Education For Nursing - Nevada            Requested
         This project became fully operational July 1, 1970 with         Fourth    Year
         the employment of a project director.     It will serve as a       $91,271
         model for the first of a four phase regional approach to
         develop a cooperative continuing nursing education program for
         the four states.   The four components  of  the  program  have  common  goals.
         However, the methodology has been  modified  in  each  to  meet  the  specific
         needs of each state and  to  maximize  use  of  their  educational  resources.

         The deans of the four baccalaureate schools of nursing conceived,
         planned and guided the  emergence  of  this  approach  to  continuing  nursing
         education. They  meet  annually  to  assure  continuance  of  its  broad
         concept.
               Fifth Year:     $97,500                 Sixth Year: $48,250 (6 mos. only)





             MOUNTAIN STATES RMP                                    RM 00032 5/71

                                                                         Requested
             Project #8 - Inhalation Therapy Continuing Education -     Fourth   Year
             This project is moving into its second year with a            $76,068
             slightly reduced request in funds.  The program which is
             devised for the states of Idaho and Nevada has offered courses
             attended by personnel throughout the region and other parts of
             tne nation. It provides information, training  and  skills  in  the
             most recent advances in pulmonary care through a two-fold program
             on a regional basis.  Faculty and supporting staff are employed
             on a part-time basis, primarily from local participants. Consulting
             services are obtained from the Mayo Clinic,  the  University  of
             Colorado and the University of California at San  Francisco  for  the
             nurse technician and the physician courses offered.

             Workshops and seminars have been conducted as well  as  other  traini ng
             courses for nurses and physicians and  inhalation  therapists.  Pre  and
             Post-tests have been administered to participants in  the  nurse  and
             technician courses, and in addition, verbal and written critiques from
             the seminars are obtained from the students, with their recommendations.


                   LF'fth Year:  $82,402

                                                                            Requested
             Project #9 - Cardiac Care Training - Las Vegas, Nevada     Fourth   Year
             The program,initiated in November 1970, is based at the        $70,737
             @i,-nrise Hospital, Las Vegas, with laboratory sessions  offered
             a@. the University of Nevada in Las-Vegas. An  additional  two  years
             support is requested.

             In addition to the project director, who is  a  cardiologist,  four
             physicians from the Las Vegas area and one from the University of
             California in San Diego, serve as faculty.  A qualified nurse educator
             is the primary nurse faculty. In addition,  faculty  and  project  staff
             from other regional coronary care programs 'have served  as  consultants
             to this pro'ect as well as sharing of  curriculum  and  teaching
             informational materials.

             Three courses for nurses are planned during the  upcoming  year  with
             15 to 18 students per course.  An accelerated program is anticipated
             for the 02 year and will include three physician courses.

                Fifth Year:  $63,700                                        Requested
                                                                          Fourth Year
             Project #10 - ConsLiltin@ Teams in Rural Areas - Nevada          $33,343
             This project is requesting limited funds for an additional
             two years after an experimental period begun  early  in  1969.  Its
             major purpose is to stimulate interest and increase skills in 'health
             professionals in isolated areas.
             A nucleus of interested, knowledgeable and pro@@lt-if-nt physicians,
             nurses and other health professionals in the Reno .4    -,@,-h#ve been
             mobilized to serve as a resource panel from which a con@6'1-'ting team
             TS drawn to visit regularly  community  hospitals.  Local  participation




            MOUNTAIN STATES RMP                      - 12 -            Rm  00032   5/71


                                              been almost 100'/., with  the   exception
            by all health professionals lia,
            of Carson City and Elko, which have the largest number      of health.
            professionals, with about 50'/. participation.
            Reaction and suggestion forms completed by participants early in
            the program indicate interest and a high level of satisfaction.
            These  forms  were  designed  primarily  to  provide  feedback.to
            consultants.  Bi-monthly  consultant  visitswill  continue   to   be
            scheduled In all  nine  communities,  and  in  addition,  evening  sessions
            will be scheduled.  The continuing nursing education program (Project #7)
            will provide nursing follow-up between visits.

                   Fifth Year:   $18,500
                                                                             Requested
                                                                            Fourth   Year
            Project #11 - Continuin@ Education for Nursing - Idaho           $89,255
            This project became operational July 1, 1970, and is based
            at the Idaho  State  University  in  Pocatello.  It  is  the  second
            phase of a regional approach to develop a cooperative continuing
            nursing education program for the region.  Its development follows
            the pattern of the Nevada  project  (Project  #7)  and  the  four
            components  have  common  goals.  The  project  director,  based  at
            Idaho State University  Department  of  Nursing  also  serves  as
            faculty for educational activities in Southeastern Idaho.  A
            second faculty  member  is  serving  Northern  Idaho  based  in  the
            Department of Nursing, Lewis and Clark Normal School at Lewiston.
            A third faculty member will be based at Boise State College and
            will serve Southwest Idaho.
                  Fifth Year:  $96,887                  Sixth   Year:   $108,459
                                                                                       Requested
                                                                                      Fourth Year
            Project #12 - ContinuinR Education for Intensive (are Personnel-            @88,827
                           Southwest Idaho -  The request for fund.s for the
            next Triennium for this project which was reviewed by the November 1970
            National Advisory Council, plus continued contributions from the are
            hospitals and the Idaho Heart Association will permit expansion of the
            effort to include more physicians and nurses.
            ]'lie program is inter-regional and inter-agency i-n character and is
            an adjunct to the oversubscribed MS/RMP coronary care training program
            originating  in  the  Missoula,  Montana  area  (Project  #2).  This  program
            will harmonize with the regional objectives and will be consistent with
            the training centers, as well as  with  the  plan  to  develop  stibregiotial
            centers of continuing education.
            A consortium of our area hospitals (St. i,tike's and St. Alpl)onstis,Boise;
            Mercy, Nampa  and  Caldwell  Memorial)  was  formed  and  their  contribution
            plus @i substantial amount  from  the  Idaho  lleart  Association,  permitted
            early implementation of the program.  It has made a significant impact
            on Southwest Idaho and Eastern Oregon.
                      Fifth Year:  $92,614                    Sixth Year:  $85,860






            MOUNTAIN STATES RMP                    - 13 -             RM 00032 5/71


                                                                               Requested
            f@roject #13 - Continuing Education for Nur,,;i.ng      offtin   Fourth Year
            ']his project was approved by the National Advisory     Council    $77,308
            on November of 1970 and became operational January      1,   1971,
            with the employment of  a  project  director.  It  is  the  third  phase
            of a regional  program  to  develop  a  cooperative  continuing  nursing
            education for the region.

            'I'lie University of ',,,Iyoming has agreed to continue the project, subject
            to availability of funds and other  resources  at  the  end  of  the  third
            year as  in  the  previous  application.  The  development  follows  the
            pattern of the Nevada proposal (Project #7).

                           Fifth Year:  $82,275              Sixth   Year:   $85,860

                                                                              Requested
            Project #15 - Continuing Education    for Nursing - Montana      fourth Year
            This is the fourth and final phase    of the continuing           $94,820
            education for the four states.  The development follows
            as the preceding  projects,  the  pattern  of  the  Nevada  program
            (Project #7).

            The project will be based  at  the  MontanaState  University  School  of
            @@ursing of  Bozeman,  with  community  health  facilities  sharing
            responsibilities.  A network of seven learning centers will be
            established with each  center  serving  one  or  two  secondary  centers
            near or at the nurse's place of employment.  Montana State University
            has agreed to  assume  responsibility  for  the  project  after  the
            first three years of  operation,  subject  to  the  availability  of  funds
            and other resources.

                         Fifth Year: $94,521             Sixth  Year:   $98,407


            .,EW PROJECTS ( Proposed for periods two and three of the Triennium)

            During the next Triennium the MS/RMII will be involved In a
            transitional period during w'nich  several  project-,  will  phase  out,
            others will be phasing down and/or developing new emphases.  The
            following programs have  been  designed  to  achieve  a  systems  change
            in manner which is viable and feasible at the grassroots level.

            Project i@16 - A Program  for  Stibregional  Development  of  Health
                           Maintenance Organizations.      The  goal  of  this
            proposal is the  stimulation  of  the  development  of  a  locally
            feasible and acceptable organization of portions of the health
            delivery system in selected communities.  The organization will
            offer:  Comprehensive  health  care  for  consumer,  including   preventive
            programs; ambulatory care services; strengthened linkages into a
            referral system; development of a specialized center; and a pre-
            payment mechanism.





             MOUNTAIN STATES RMP                      14 -           Rm  o6O32   5/71


             The proposal is correlated with the accompanying one dealing with
             manpower utilization, which will  stimulate  readiness  for  HMOs  which  will
             be feasible at the local level and commensurate with national and
             regional goals.

             The "systems transformation" called for  by  this  program  consists  of
             successive community adoptions  and  refinements  of  revised  organizational
             patterns for improved delivery in specific communities.

                      Fifth Year: $49,400             Sixth Year: $110,285

             Project #17    Improved Utilization through  Expanded  Roles  of  Existing
                           Manpower.  The  proposal  will  support  extensive  development
             of more effective patterns of  manpower  utilization  in  rural  communities.
             Tt will concurrently support the training of a "middle-level practitioner"
             category and facilitates  their  introduction  through  community  based
             manpower  reorganization  efforts.  Specific  activities  will  include
             health personnel training and  collaborative  learning  of  new  styles
             of working arrangements.

             Specific designs will be based on individual characteristics of
             communities and based on involvement of  the  key  health  services  and
             health resource personnel.  A coordinated      planning and administrative
             mechanism will be maintained at the regional level.

                      Fifth Year:   $58,900              Sixth Year:.$70,800


             Project lkl8 - Centers for Care of Childhood Disorders - This     proposal
             will attempt to reduce infant mortality and morbidity in the      neonatal
             period and prevent long-term sequelae of birth-associated events
             for infants in the Mountain States area.  This is only one aspect
             of a comprehensive program of maternal and child health.  The  prbgr@.ii7i
             will designate regional centers through evaluation of vital
             statistical data, geography  and  transportation  factors  and  medical
             specialists available. Secondly,  centers  will  be  designated  to  train
             personnel.  Faculty (physicians and nurses) will be recruited and
             equipment will  be  obtained  for  demonstration  teaching.  Evaluation
             will include data,measuring the centers' ability to correct life
             threatening conditions through the use of trained personnel and
             special equipment and facilities and overall improvement in neonatal
             death rates.

                    Fifth Year:  $78,000                  Sixth Year:  $100,000


             Project #19 - Extension of Cancer Centers -  The  purposes  of  this  project
             are identical to Project #3, which established in Boise a regional cancer
             diagnostic and treamtment resource,  (MSTI)  which  in  addition  provides
             intensive and continuous cancer  education  program  for  medical,  dental
             and allied health personnel.





             @IOUNTAIN STATES RMP                   - 15 -         RM 00032 5/71


             Funds are requested for establishing in a centrally  located  community
             -in Montana, a similar resource. There are three hospitals  and  about
             40 physicians w@io provide major medi.cal specialty referral services
             for eastern Montana. Both cobalt and chemotherapy are  available  to  a
             limited degree but services are fragmented.  The center planned for
             this will follow the concept of MSTI in Boise.

             A Linifi.ed center similar also to MSTI is also planned for Las Vegas,
             Nevada.  There has been much interest and enthusiasm by health interests
             in the area for such a center. It will serve a  community  of  300,000
             residents, utilizing the MSTI as a prototype. Core  staff  will  assist
             in planning and development.

                        Fourth Year:  $50,000            Fifth Year:  $70,000


             ?roject 4@20 - Preparation of Physicians as T,?achers -  The  proposal
             calls for the development of new and relevant  educational  skills  for
             key health practitioners in the new subregional system for continuing
             education. This will  provide  key  health  practitioners--particularly
             selected physicians with advanced skills in emerging and existing
             medical and health education opportunities.

             Preparation of physicians and other 'health personnel as  key  teachers
             in stibregional centers will be accomplished through  ail  educational
             design which: (1) provides for reducing the "knowledge-practice gap";
             (2) provides a "renewal" experience to give participants a competence
             to effect significantcommunity changes in medical  care  practice:  and
             (3) provide competence to create and sustain an optimal learning
             environment allowing for increased discipline competence and more
             productive interdependent behavior directly related to the community's
             overall health system effectiveness.

                          Fourth Year:  $62,441            Fifth Year:  $92,800


             Project #21 - Laboratory and Radiography Improvement  Program  -  This
             program will be designed to improve and make  more  readily  available,
             reliable clinical laboratory and radiography services.  This will
             be very significant in the overall improvement of medical care
             in rural areas.  Subregion committees will be utilized and consist
             of consumer representatives, as well as all health professionals
             (including hospital administrators) having an interest in  linica
             laboratory and radiography performance.
             The program will utilize local resources to the maximum; and
             the system will be largely self-supporting.  All aspects of the
             program will be identified with the subregional committee and not
             with any official agency or professional group.  Cooperation of
             state and local health departments, community hospitals and
             professional groups, through appropriate official representation





           'IOUNTAIN'STATES RMP                - 16                 RM 00032  5/71


           on the subregional committees, will be emphasized.,  Cod6 numbers
           will guard the anonymity of laboratories and  radiology departments.

           A well-trained experienced technologist wit  some teathi ng methodology
           will be employed'as project director.  He will coordinate all
           continuing education and quality control programs and serve as
           executive secretary of the overall committee.  Each subregion will
           employ a part-time person (25%) to work with local committees and
           assist the project director carry out program ictivities in his
           own area.


                     Fourth Year:  $40,000            Fifth Year:  $50,000



















                                                 RMPS /GRB /3 /I/71











                                                                                                                                                                            REGIC'           iviO'-iN'TAIN  STATES
                                                                                                                                                                            CYCT i-:         RM  00032        5/71
                                                                                          B--EAY,OUT  OF  REQ'JEST                       04                  PE.DIOD                         (Triennium)


                                                    O."                       CONTIN',j!N"G         i                      'zpi'@VTC,"S:,Y             Nr-@!                I
                                                                              A;@'T7VTT-@ES
                                                                                                    @REZE,AAL              fAPPR/UNF@'N.IACTTVTTIES                           DIRECT            !!.%'DIRECT                 TO-.AL

                                                                                                                                                      $71,001)                     71,000       @$21.927
                                                                                      $1,159,109
                                                                                                                                                                            il,159,109          @1233.L25                       1,292.5@4
                                    C(--oni7-v  C,-rc,  Tr@inin@:                                               582        i
                                                                                                       $148                                                                          ',-48.582     25                       174,197
                                                                                                                     2                                                                  1   79
                                    C 1:
                                                           Prof.                   76,177                                                                                          7 6 :1 7  7        -0-                          75.,77
                                                                                                                                                                                       166,271     I(,.5j,2'                         7).-
                                                                                         2    71
                                                                                   91.271                                                                                          91,271          21i,752
                                    -n-P                                           7     0 ') (1)                                                                                  76,0t')S        i 0, @, I
                                                                                   @1)       7@-                                                                                   7n.7'17
                                                                                   33,    31@3                                                                                     33  ,   343      T,--3  5  9              35.  7   C,@
                                                           (if!@ho)                S@)   2 5  5                                                                                    89.25   5       2 0.  61  3              1 0
                        fr-12                       C@re  Trc-'-ning                     C. @- 7                                                                                   83,827                 8,882
                                                                                                                                                                                   7  @   1)@4     3,,(339
                                    c--     r       r -               -nin         77.31,)@
                           "5
                                    C7-  'c-                                       94,   82    0                                                                                   ,4,820          20,    F,33.             I-         .3


                                                    cole      oi:
                                    Ixis,,ne  @,lanpower                                                                                                  ---                      ---
                         @'18       Cc-,i',crs  for  Care         of

                       @;r;19       E@-tenrion  of  C:?ncer

                       -r,20  -     Pre"zrction  of  P',I)I!Z.

                                    Lz!@orntorv       &           Ra(7iogrcT"@y
                                    a-,X-C






                                                                            ,$2,        023,l@06        355, 7 54                                     $71,000               $2,1@49,940         @507,136                     $2,95/-,C,-6
                                    First  year  of  Trienniu-ii              (3rd          year                          t@ be      considered       as       part       of: renewkil.














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                                                                                                                   BR--AKOUT            OF            REQUEST 0                     PERIOD
                                                                                                                                                                                                                                                         RY,       00011,2       5/71

                                           7 C,"@ I C)'
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                                                                     7r,. 1 29
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                                                                                                                                                                                                                                           2@8,229
                                                                                                  172                                                                             2r'7.172!    C, 1: 1,
                                                                                                                                                                                                                                                    7(,.177           76,11-,7
                                                                                                                                                                                                                                             r@,',.   ?   7
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                                                                                                                                                                                             .2),7@@,               I-,2,lr
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                                                                    c) 7   1 r                                                                                                                                      1 n @i , 2,,-          2   7,q.    01)7
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                                                                                                                                                                                                     I. (,',  :
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                                                                                                                                                                                                                                               7 . 7
                                                                                                                                                     110,285      1       1 1     2    q.@
                                                                                                                                                                                                                                           1 5           5
                                                                                                                                                        ')OO                7 0.                                      7@.     S('o         1 2 0 ,  7(,@-)         1 2.          7nn
                                                                                                                                               7 0.
                                                                                                                                             i 0,      01,,P              1 O,).    O()(',                          I   01)   (,@n         1  7-   ,   O@O         1  7          o@o
                                                                                                                                                         000                7 C) . fl)
                                                                                                                                                                                                                      70,     or,)         120.000          i      1  2  O,.   or.(I
                                                                                                                                               92.     1,@00                1)2  ,   -,Of@                            92  .   301)         15 5  ,  2  41,            5 5
                                                                                                                                                      50.000                         50,000                                                          90,000           90,0(@o












                                                           $'@,714,271                  '@207,172
                                                                                                                                        $5r)4,885                $2,486,-@2              $470,748                      @2,957,071,
                                                                                                                                                                                                                                                $7,553,810               $9,047,3111




                                                               .(A Privileged Comniu.nication)



                                 SU@MRY OF REVIEW  A.ND  CONCLLTSIOI\L  OF
                                      A@DRIL 1971 REVIF,,UL COMMITTEE


                              MOUNTAIN STATES REGIONAL MEDICAL PROGRAM
                                            RM 00032 5/71


                          FOR CONSIDERATION BY MAY 1971     ADVISORY COUNCIL


            RECOMMEI\TDATION:   The Committee recommends    approval of triennial funding
                                to include the developmental component at the following
                                direct cost 16vels:

                  Year                             e@st                  Recommended

                    04                         $2,44.9,940               $1,741,000
                    05                           2@617,542                  1,511,000
                    06                          -2,486,328                1 5 36 .2 0
                    Total                       $7,553,810               $4,618,000

            No renal activities were proposed.


               -TI UE:  Two  members  of  the  site  visit  team  presented  findings  from
                        the Yierch 8-9 site visit which'was held in Boise, Idaho and
            Reno, Nevada.  The  Boise  portion  of  the  visit  was  devoted  to  study  of
            the  organization,  progress,  and  future  plans  for  the  Mountain  States
            RMP as a  whole,  while  the  Reno  portion  of  the  visit  was  concentrate
            on plans for a proposed  Neva(-la  RIIP,  separate  from  the  Mountain  States
            Program.

            The team  learned that  the  RMP  has  developed  an  effective  network  for
            health  planning  in  the  four-state  area.  Several  of  the   operational
            projects have been outstanding in promoting better patient care services.
            The Regional Director has successfully recruited and retained excellent
            Core staffs.

            Subregionalization  has  been  effected  through  the  establishment   of   the
            fout-state  office,  while  the  regional  headquarters  at  Boise  has  been
            instrumental  in  seeding  effective  program  activities   throughout   the
            Region. The  RAG  has  been  reorganized  from  an  original  group  of  160,
            to a more manageable And effective number of 26.  How6ver, the present
            membership is too  heavily  we'ialited  toward  physicians;  the  RAG  needs
            to  be  broadened  with  Allied  Health  and  consumer   representatives.
            Both the RAG and the State groupings of practicing physicians and nurses,
            community  hospitals,  voluntary  and  official  health  agencies   appear   to
            be well versed on the needs  for  priority  seti-linc,  and  decision  makin

            Core staff has been instrumental in initiating a       number  of   community
            activities in priority areas.  The team felt the       Reg!-on is able to
            accept responsibility for developmental fuj-.iding-

            The team also reported that the iiove toward separate RMP status by
            Nevada a peared to be very amicable.  Both WICIIE, the grantee
                     p





           MOUNTAIN STATES RMP                     -2-               RM 00032 5/71

           organization, and the Mountain States staff appear ready to  assist
           Nevada in its next steps; the @IP has been a positive resource in
           the development of the new medical school in Nevada.  The separation
           issue will be fully explored in the next year.  The reviewers agreed
           with the site team's recommendation that a dialogue begin with  all
           interested parties--representatives from Boise, Boulder, Reno  and,
           the RAG--to explore means of accomplishing mutually acceptable
           solutions to all issues involved with autonomy for Nevada as.a
           separate RMP.

           The Committee concurred with the site visitors' recommendations
           regarding the approval of developmental component funding and three-
           year support for the Region.  The Committee noted that the continuing
           education programs in the four states need better coordination  and
           that EMP support for the Mountain States Tumor Institute should  be
           limited to two more years.  The Region should also be advised to
           broaden its RAG membership.










                                                     RMPS/GRB/4/26/71






                              DEPK., flAEN-rOF HEALTI-1, EDIJCATIOI@,l, ANr, IELFARE

                                               PUIBLIC HI@'ALTH SERVICE
                               HEALTFI SERVICES AND WIF:NTAL HEAI-TH ADN41NISTRATION



                  Mar6b 16, 1971



                  Mountain States (WICHE) Site Visit

           ,o:    Harold Margulies, M.D.
                  Acting Director
                  .Regiorfal  Medical  Programs   Service
                  Through,   Sarah J. Silsbee
                             Chief
                             Grants Review Branch

                  This i s a "mini"  site  visit  report  to  give  you  a  very  general  and
                  condensed  impression of the regionts present status.  The team was
                  composed of the following members.-

                                    Clark H. Millikan, M.D., Chairman
                                    Henry  Lernon,   M.D.
                                    Willard A. Wright, M.D.
                                    Miss Dorothy E. Anderson, RiN.
                                    Herbert B. Pahl, Ph.D.
                                    Jessie   F.   Salazar
                                    Miss ElsA J. Nelson
                                    Rodney Mercker
                                    Richard F. Clanton, JR.
                                    Daniel.  P.   Webster


                  The first day, March 8, was spent in.Boise, with all four state
                  offices and the regional Core staff and '@,7ICHE represented by
                  Dr. Kevin Bunnell, from IQICHE, who is the Coordinator, ind
                  Mr.  John  Staley,  the  Fiscal  Management  Officer.   Dr.   Popma   serves
                  as Regional Director-  Dr. Bunnell discussed the relationshi  'of
                                                                                        p
                  the  MS/RMP  to  WICHE,  which  is  the  grantee   organization.   WICIIE
                  has provided the cohesiveness and sound fiscal. management to the
                  region, And in addition  filled the role of "cente-r- of excellence"
                  which did not exist in any of the four states Prior to RMP.  While
                  the  WICHE  Commission  (39  members)  has  overall  power   to   criticize,
                  and even reject, program suggestions, there is no evidence that
                  tb6te has been any conflict produced by this authority.

                  The RAG has b,@-@cn reorganized., f-rt)m an             group numbering
                  about 160, to a uiorf., manageable and effective size.       The    Group
                  needs  strengthening  @--c  include  a  representative  of  alabor    union,
                  minority  group  or  someone  who  would  be  considered   an "average"
                  consumer,  The  new  Chairman  is  Exe,-uti.ve  Director   of Wyoming    Blue
                  Cross-Blue Shi@@ld.




                PAge 2 - Dr. M--.gulies

                Sub-r6gional development is progressing.  An      example of this is the
                Mo tana and Educational Foundation which was      funded by@Proect #5,
                July 1,@1969.  The Foundation has a Board of      13'me-,nbers which  has
                produced  81  separate  educational  programs,  attended  by   3,600
                individuals.  Currently  the  Board  is  reviewing  priorities  of   this
                organization; looking  at  problems  related  to  the  need  for  health
                manpower  development  and  how  this  might  be  expedited.  They  may
                explore prospects of becoming more active in the development of ID10s.

                Dr. Grizzle  (Wyoming)  reported  that  through  IIS/RMP's  efforts  in
                sub-regionalization, a new record system was developed. at the Big Horn
                Hospital wbich,is  now  being  extended  to  other  hospitals  in  the  area.
                Also, the University of Wyoming has now taken over the responsibility
                for the communication network originally developed by RMP.

                The Mountain  States  Tumor  Institute  in  Boise  treated  770  patients
                last year, and the  estimate  is  for  about  1500  patients  for  Idaho
                Alone in the  current  year.  The  team  made  some  suggestions  to  be  re-
                layed to  St.  Luke's  Hospital  Board  of  Trustees  for  diversifying
                its funding sources.  The site team visited the new facility which
                will soon be ready for occupancy.

                MS/Pl4P has  wisely  concentrated  on  objectives  via  their  projects
                which  were  capable  of  accomplishment  and  have  led  to  formation
                of  "contact  points"  throughout  the  four   States.   They.sbould
                probably now direct their attention to the design of other programs
                which  may  be  introduced  into  the  already  established  system.

                The  site  visit  team  addressed  the  question  of  administrative
                methods for  priority  setting  and  decision  making  in  terms  of  program
                content, budgetary considerations, etc.  The team learned that
                An Executive Committee,  working  with  the  RAG  will  work  out  recom-
                mendations  for  budget  cuts,  And  each  State  subregion  will  also
                develop its recommendations.

                The two sets  of  recommendations  will  be  negotiated  into  one  list
                which  will  be  reviewed  by  the  Executive  Committee,  If  necessary,
                it will be considered by each 8ub-region again, and thence to
                the RAG.for final action.

                The team was  assured  that  MS/RMP  fully  understands  that  the  RAG
                carries'the  responsibility  for  the  important   concept   of-priority
                setting and decl'sion-making.  Also, pr,-,cticingwphysicians and organized
                medicine   community hospitals, voluntary and. official. health agencies
                are playing a significant role in the fo-Ur--state program.  Participatio@-I
                and  involvement  of  nursing  professionals  is  expensive.  There   is
                amp;16  evidence  that  Core  activities  have  resulted  in  actiou-oriented
                planning, particularly in local level co@T,,ffiuriity  organization  and
                planning i.ei, CHP and Model Citi     es.





               Page 3 - Dr. Ma@gulies

               The second,day (March 9)'was spent in Reno, at the University  of
               Nevada., To quote.Dr. Millikan, if there bad been a big  bonfire
               going (for separation), it had been dampened considerably  before
               the confrontation with the visiting team. Dr.  Georg6  Smith,  Dean
               of the School of Medical Sciences, was Chairman. A,lthough@- Dr. Smith
               delineated about eight reasons for Nevada's wish to become  an
               autonomous RMP, there was no real description on his part,, or others
               who spoke for the Nevada group, of what would be  done  differently
               -if they were independently organized. The Nevada group appears.to  be
               quite far away from the development of a concept of  the  necessary
               organizational structure, objectives, etc., in terms of  local
               capability In other words, there  was-conclusive  evidence  that
               planning has not proceeded very far,  The presentation in Reno
               was a most interesting description of educational opportunities  in
               Nevada, both at an undergraduate level and the new two-year  medical
               school. BUT, there was no definition of the roles to be  played  by
               the "N6vada Regional Medical Program."

               Doctor Fred M. Anderson, Member of the Board of Regents,  University
               of Nevada and Commissioner from Nevada to WICHE., as well as Member
               of the Nevada Section of MS/RMP RAO, reported that statewide  elements
               favor autonomy as soon as feasible for Nevada. He suggested  as  one
               possiblity, an affiliation agreement with WICHE on an interim  basis
               to benefit from WICHE's expertise in planning, while Nevada  continues
               to plan for full autonomy with the University as the  grantee.
               Doctor Pahl discussed briefly the "transition scheduling", in  terms
               of a target date for separation and referred to timing  factors  in
               line with-preparation of new applications, review cycles,  etc.  The
               suggestion wag made that perhaps a small group which would  be
               representative of  WI.CHE MS/RMP and Nevada could meet to work  out-a
               plan of procedure, which, in turn could be presented  for  National
               Advisory Council consideration and advice.
               Dr. Millikan pointed out that the split in South Dakota and Nebraska
               was not viewed.by RMPS and the N.A.C. as a precedent upon  which
               Nevada (or any other region) could build its case for  secession.
               Each is.a distinct phenomena and with many differences.readily
               apparent. He was complimentary to the Nevada and to  the  MS/RMP
               t6p e8ontatives in its desire for orderly procedures in  steps
               to establish Autonomy.  He emphasized the need for an organizational
               matrix to stimulate staff int6r-relationsbips and provide  the
               environment for a series of dialogues. This should  include,  of
               course, identification of the requirements of WICHE and give  due
                   'deratibn to needs of all four states.
               consi

                     'Bunnell, in stating WICHE's position in the  Nevada  separa-
               Doctor
               tion expressed the opinion that all of the points raised by  Nevada
               are resolvable, but, mutually beneficial resolutions will  have  to
               be negotiated with representatives of Reno, Boise and  Boulder
                                                                           , 0
               Results must be beneficial to all concerned.




             Page 4 - Dr. MarL,  Les

             The team discussed very briefly the  effect  of the cut in funds to
             the overall program, but did  not  specifically pin down items for
             such cutsi Doctors Popma and  Cerdes  listed  anumber of  areas  where
             reductions would not result in appreciable  amage to t e program.

             The region has exhibited expert know how in 'developing  an  effective
             network for health planning in this large four state area.  The
             Regional Director has been successful in recruiting and retaining
             an excellent Cote staff.  The site visitors noted that sub-regionaliza-
             tion through the establishment of four state offices, plus the
             regional headquarters office in Boise  entails  considerable  expense.
             There was agreement, however, that this cost is justified when one
             considers the significant impact of this means of distributing RMP
             activities to many communities of varying size throughout the four
             Stat6s*

             The consultants recommended approval of  the  Developmental  Component
             in an amount to be commensurate with pending overall budget
             negotiations.




                                                         sie F. Salazar
                                                      Public Health Advisor
                                                      Grants Review Branc




                                                               A Privileged Communication
                                                               RM 00032



                                        SITE VISIT REPORT
                            MOUNTAIN STATES REGIONAL MEDICAL PROGRAMS

                                        March 8-9, 1971



             SITE VISITORS
             Clark H. Millikan, M:D., Chairman, Consultant in Neurology, Mayo
             Clinic, Rochester, Minnesota, Member, National Advisory Council
             Henry M. Lemon, M.D., Professor of Medicine, Nebraska Medical School,
             University of Nebraska, Omaha, Nebraska, Member, Review Committee

             CONSULTANTS

             Willard A. Wright, M.D., Director, North Dakota RMP, Crand Forks,,
             North Dakota

             Dorothy E. Anderson, R.N., M.P.H., A,ssistant Coordinator, Community
             Programs, California RMP Area V, Alhambra, California

             REGIONAL MEDICAL PROGRAMS SERVICE STAFF

             Herbert 8. Pahl, Ph.D., Acting Deputy Director, RMPS
             Jessie F. Salazar, Public Health Advisory, Grants Review Branch
             Elsa J. Nelson, Specialist for Program  Development,  Continuing  Education
               and Training Branch
             Rodney Mercker, Crants Management Officer, Grant4 Management Branch
             Richard F. Clanton, Jr., Operations Officer,  Regional  Development  Branch
             Daniel P. Webster, Regional Office Representative, Region VIII

             MOUNTAIN STATES REGIONAL MEDICAL PROGRAM STAFF

             Alfred M. Popma, M.D., Regional Director, Boise, Idaho
             John W. Gerdes, Ph.D., Deputy Director, Boise, Idaho
             Kevin P. Bunnell, td.D., Coordinator, Boulder, Colorado
             Laura C. Larson, R.N., M.A., Coordinator of Nursing and Allied Health, Boise
             Charles E. Smith, Ph.D., Coordinator Planning and Development, Boise
             Mrs. Helen Thomson, Coorinator of Information, Boise, Idaho
             Fred 0' Graeber, M.D., Director, Idaho Subregion, Boigei Idaho
             Sidney C. Pratt, M.D., Director, Montana Subregion, (.;rest Falls,  Montana
             Joseph B. Deisher, M.D., Director, Nevada Subregion  'Reno, Nevada
             Claude 0. Grizzle, M.D., Director, Wyoming, Subregion, Cheyenne,  I-lyoming
             Donald Erickson, M.A., Educational Specialist, Wyoming Subregiono Cheyenne
             Mrs. Helen Alexander, Assistant Director for Administration, Montana
               Subregioft' Great Falls, Montana
             Louise Alcott, R.N., Assistant Director for Administration, Nevada Subregion$
               Reno, Nejada
             Wilma Frederickson, Staff Associate, Nevada Subregion, Reno, Nevada
             Bette Jean Tranum, Administrative Secretary, Boise, Idaho
             John Staley, Administrative Services Officer, Boulder, Colorado




             MOUNTAIN STATES RMP                     2 -            RM 00032


             REGIONAL ADVISORY GROUP
             Arthur R. Abbey, Chairman, RAG; Executive Director, Wyoming Blue Cross/
               Blue Shield; Cheyenne, Wyoming
             l,aura 0. Walker, Ph.D., Vice-Chairmn, RAG, Head, School of Nursing,
               Montana StateIUniversity; Bozeman, Montana
             Charles A. Terhune, M.D., Immediate Past Chairman & current member, RAG;
               Practicing Physician, Burley, Idaho

             WICHE COMMISSIONERS
             Dermont Melick, M.D., Chiirman, WICHE Commission Regional Programs;
               Coordinator, Arizonza RMP- Professor of Surgery, Arizona College of
               Medicine; Tucson, Arizona
             Thomas Tucker, Ed.D., WICHE Commissioner: Chairman, Department of School
               Administration & Supervision, University of Nevada; Reno, Nevada
             Juanita White, Ph.D., WICHT Commissioner; Nevada State Representative;
               Boulder City, Nevada
             Fred M. Anderson, M.D., WICHE Commissioner; Practicing Surgeon; Board
               Regents, University of Nevada; Reno, Nevada


             OTHERS
             Loryp A. Kopan, Administrator, Veterans Administration Center; Ex officio
               Member, Regional Advisory Group; Boise, Idaho
             E. E. Gilbertson, Administrator, St. Lukes's Hospital; Boise, Idaho
             Maurice M. Burkholder, M.D., Practicing Physician; Boise, Idaho
             Ronald Koons, M.D., Head, Radiation Therapy,. Mountain States Tumor
               Institute, St. Luke's Hospital; Boise, Idaho
             Ra@ Cottner, Assistant Administrator, St. Luke's Hospital; Boise,  Idaho
             Shirlee Koons, R.N., Nurse,Coordinator, Mountain States Tumor  Institute
               St. Luke's Hospital; Boise, Idaho
             Marie Crisp, R.N., Chief-;Technologist, Mountain States Tumor  Institute
               Boise, Idaho
                                Member, Core Committee for Mountain States Tumor
             George Baker, M.D.,
               Institute, Practicing Physician; Boise, Idaho
             Cl.enn Talboy, M.D., Member, Core Committee for Mountain States Tumor
               Institute; Practicing Surgeon; Boise, Idaho
             Verne Reynolds, M.D., Member, Core Committee for Mountain States Tumor
               Institute:  Practicing Gynecologist; Boise, Idaho
             Alfred Stone, M.D., Member, Core Committee for Mountain States Tumor
               Institute. Chief, De artment of Radiology, St. Luke's Hospital;  Boise
                        0          p
             John Edwards, M.D., Practicing Physician; Idaho State Representative;
               Council, Idaho
             Kay Ortman, R.N., Recent Graduate, Stanford University Nurse Clinician
               Training Program; Cambridge, Idaho
             Ethelda Thel6n, R.N., Program,Coordinator, Continuing Education for Nursing
               Nevada; Reno, Nevada
             George Smith, M.D., Practicing Physician; Dean, Medical School, University
               of Nevada; Reno, Nevada




             MOUNTAIN STATES RMP                 - 3 -                RM 00032
   4D        Oli,tiERS (cont.) I
             Thomas S. White, IA.D., Practicing Physician; Member Regional Advisory
               Group; Boulder City, Nevada
             Richard Licata, Ph.D., Professor of Anatomy, University of Nevada; Member
               Regional Advisory Group; Reno, Nevada
             Marjorie J. Elmore, Ed.D., Head, Or@is School of Nursing, University of
               Nevada; Member Regional Advisory Group; Reno, Nevada
             Dean Fletcher, Ph.D., Professor of Cancer Research, University of Nevada;
               Reno, Nevada
             David Brandsness, Administrator, Sunrise Hospital; Member Regional Advisory
               Group; Las Vegas, Nevada
             Hugh Collett, M.D., Practicing Physician; Elko Nevada
             N'. Edd Miller, Ph.D., President, University of Nevada; RenoNevada
             Veriyn Elliott, MiD. President, Nevada Medical Society; Fallon, Nevada



         Mountain States Site Visit Report            -4-            RM  00032


         INTRODUCTION: The first day of the site visit was  spent  in  Boise,  with  all
         four-state offices and the Regional Core Staff  4nd  WICHE  represented.
         Dr. Kevin Bunnell discussed the relationship of the Mountain States
         Regional Medical Program to WICHE, the grantee organization.  WICHE    has
         obviously provided the  cohesiveness and sound fiscal management to    the
         region, and in addition, filled the role of  "center  of  excellence"  which
         did not exist in any  of the four states prior to RMP.
         REGIONAL ADVISORY GROUP:  The RAG has been reorganized, from an original
         group of about 160, to a more manageable and effecti'e  number  of  26.  The
                                                              v
         site team felt that this is a much more realistic and  workable  group,  and
         in  accord with the previous site visit recommendations.  However,  the  team
         found  the Group to be largely weighted with..medical people and generally
         inadequate in alliedhealth and  consumer  interests.  There  was  almost
         unanimous agreement that the Group will be strengthened and enriched by
         including representatives of labor, minorities or other "average"
         consumers.  The new RAG Chairman is Executive Director of Wyoming.Bltie
         Cross-Blue Shield.
         The recently inaugurated review procedures developed for  the  RAG  seem
         to be quite comprehensive and workable. -These  should  benefit  also
         by greater input from the broadening of membership  referred  to  above.
         GOALS, OBJECTIVES AND PRIORITIES:  There  was  neatly  uniform agreement
         from the site visitors that the goal, of improving the  health  care  of the
         largely rural residents of the four-state Area  was  the  most over-riding
         of the four that are stated. The  goals  of  manpower  development  and  health
         center development appear subordinate  to  these.  The  region seems to  have
         very adequately assessed its needs,  problems  and  resources; objectives
         and goals are congruent with  national  priorities.  To  some  extent,  funding
         of operational programs to date appear  to  have  beendevelbped  with
         political considerations in mind to give each one  of  the  states  some  share
         in activity, This seemed to the  team  an  entirely  reasonable  and  necessary
         consideration.
         ORGANIZATIONAL EFFECTIVENESS: Dr. Popma,  the  Regional  Director,  has  served
         in an outstanding manner as a  result of his broad experience and involvement
         with Regional Medical Programs on a national level, and his keen sense
         of the qualifications required by  his  organization.  The  team  agreed
         that the Core staff, which reflects a broad range  of  professional  and
         management competence in all areas  is  highly  effective.  Noted  particularly
         was the management and fiscal responsibility  which  falls  under  the  purview
         of WICHE. One of the strongest  features  of  the  MS/RMP  organization,is  the
         sub-regional activity, which seems to be proceeding well, especially in
         Wyoming, Montana and Idaho. Nevada was  considered-to  be  somewhat  less  well
         developed in this regard,.possibly due to its greater distance and isolation.
         While sub-regionalization appears expensive, it has proved important in
         maintaining liaison throughout the four-state area,  and  as  a  framework  for
         future development in improved patterns of  medical  care.  The  grantee
         organization (WICHE) traditionally embodies an  even  larger  number  of
         western states for educational purposes, which  has  strengthened  this  aspect




            Mountain States Site Visit Re'port             -5-             RM    00032


              of MS/RMP,  The site team was unable to determine the real extent of
              relationships with Comprehensive Health Planning on either the  A  or  B
              levels. Indeed, the team did not glean any  positive  impressions  of
              CHP activities in any of the four states.
              Regional resources are well utilized in all four  states.  There  was
              feeling, however, that lacking is an involvement in  non-government  and
              private industrial interests, i.e., the copper companies in Montana and
              the Boise-Cascade Corporation in Boise. These might prove  to  be  an
              excellent source of lay individuals, who can serve an effective role
              in hea.Lth planning.
              Practicing physicians and organized medicine are significantly supporting
              and participating in the program. Many  community  hospitals,  including
              their boards and staffs are firmly committed and involved.  The involvement
              of nursing professionals is extensive. It general,  there  seems  to  be
              satisfactory political and economic interaction in the MS/RMP.  One infet-
              esting development is WAMI, a program emanating from the  University  of
              Washington School of Medicine, aimed at increasing the output of
              physicians by getting peripheral educational and community health facilities
              personnel involved in the training of doctors.  Idaho  and  Montana  are
              actively involved in this plan.
              ASSESSMENT OF NEEDS, PROBLEMS,AND RESOURCES: The  site  team  felt  that
              these havetbeen adequate in most respects, but planning appears to
              have been limited to the immediate future.  For instance, in the Mountain
              States Tumor Institute program, (based in St. Luke's Hospital),  it  was
              clear that planning has thus far been rather limited in scope, that the
              full scientific potential of the enterprise has not been   planned for, and
              as yet no formal linkage to a state college unit has been developed.  This
              would provide the avenue for educational funding, which will be needed to
              make the Institute a real community asset.  It  was  suggested  that  an
              exploration of an affiliation with the Boise State College might lead to
              development of a School of Allied Health based at St. Luke's and St. A!Ohonso
              Hospitals.  The team also recommended that the Board of St. Luke's consider
              the development of a Scientific Advisory Cormnittee, with thought given to
              planning for other medical disciplines.  It was noted that there is a very
              excellent surgeon engaged in a large volume of angtography in Boise, and
              Also that 75% of the 150 practicing physicians in Boise are spec a  sts.
              In time, the Mountain States Tumor Institute could become a multicategorical
              health resource.  The team also suggested that cancer center planning grant,
              or other federal support, should be explored with  the  National  Cancer
              Institute.

              PROGRAM ACCOMPLISHMENTS: Outstanding is  the  impressive  coronary  care
              training program in the Montana area, and the nucleus  of  an  excellent
              cancer care activity in the Mountain States Tumor  Institute  in  Boise.
              Further, RMP outreach to selected communities in  developing  the  nurse
              practitioner program through a realistic method of obtaining individuals
              who can contribute to local health care is representative.  Also, there
              is evidence of adequate surveillance of ongoing  activities  via  the
              sub-regionalization network.  This shows great promise for future




         Mountain States Site Visit Report              -6-            RM   00032


         development, particularly in rural health care if  the  Core  staff  sub-
         regionalization organization is preserved.  The nurse practitioner
         program will need to develop its own training  program-in  view  of  the
         discontinuance of Stanford's.

         The visitors believed that operational programs  developed  in  this  region
         have faithfully reflected the region's  initiallobjectives  of  improving  -           y
         postgraduate educational availability  for  practitioners  by  bringing  the
         program to medical and nursing practitioners.  Missing,  as  far  as  could
         be determined by the team, is dental or allied health training on a
         continuing basis.  These efforts have been intermittent.
         The postgraduate educational activities appear to  be  quite  diverse  and
         fragmented throughout the states, and rather loosely coordinated
         by the regional office. These programs  have  been  expensive  in  terms
         of travel funds and consultant fees.  However,  evaluation  of  the  impact
         of some of these activities, particularly the  coronary  care  program,  has
         indicated positive results. This has  been  particularly  notable  in  small
         community hospitals in  influencing  physicians'and  nurses'coronary  care
         procedures.
         The MS/RMP realizes that it is now moving beyond the phase of postgraduate
         training and is beginning to think about the  generation  of  new  manpower.
         The region is faced by the necessity for major cuts in the approx    imately
         $800,000 of the continuing education  request.  While  such  programs  have
         strengthened the image of Regional Medical  Programs  throughout  the  four
         states they have also been an excellent proving ground.to many     health
         professionals in the.four states  for what can be accomplished    through
         future cooperative efforts.
         There was concern on the part of the site visitors  that  in  planning  for
         present and future operational activities, Stroke  has  almost  been  tom-
         pletely by-passed. The team expressed the hope  that  in  due  course  this
         omission can be alleviated.
         The expanded Mountain States Tumor  Institute  facility,  already  referred
         to above, will be in operation later this  year.  The  planning  for  this
         facility has been excellent and includes prospects for  ten  stories  to  be
         constructed stop the present basement level  unit.  The  MSTI  is  seeking
         the services of a radiotherapist, a chemoth6rapist, a physicist, a
         social worker and technicians. The Institute  is  beginning  to  break  even
         in terms of fees and grant funds.  In 1970 there were 300 new radiotherapy
         cases, 400 chemotherapy patients and 70 old cases, all of whom paid fees.
         The new patient load that is anticipated with the  opening  of  the  new
         facility is 700.  The hospital board's failure to think in somewhat
         broader terms of a future, multicategorical  facility  has  already  been
         referred to under Assessment of Needs, Problems and Resources.  The
         site team emphasized that the hospital board should think about developing
         a Scientific Advisory Committee which could, in turn, broaden the horizon
         for the Institute and develop into a major health  resource,  not  only  in
         cancer, but in cardiovascular and neurological diseases as well.




             Mountain States Site Visit Report          @7-              RM 00032

             The influence of Regional Medical Program activities is quite evident
             in the Nevada area, largely due to the interest of the Reno physicians
             and the development of the new medical school.  This is most apparent
             in planning for the training activities of the school.
             The team was interested to hear from the Deputy-Direct6r that he viewed
             the lack of a medical school in the region as one thing that has
             influenced the emergence of interaction of local talent in a manner
             that might not have evolved if medical school leadership had been
             available.
             The Montana Medical and Educational Foundation (Project #5) was funde
             July 1, 1969.  It is directed by a Board of thirteen members which has
             produced 81 separate educational programs, attended by 3,600 individuals.
             The concept provides a multidisciplinary approach to continuing education
             for all health professionals.  With funds expiring in March 1972, the
             RAG is now studying ways and means of attracting other resources, perhaps
             by providing some service as well as educational functions.  Long-range
             plans for the program, which now crosses state lines into Idaho, Montana,
             Wyoming and North Dakota .  Eventually it will move into existing or
             future university systems.  Also under consideration is the prospect
             of becoming more active in the development of HMOs.   ,
             The site visitors were interested to learn that the University of
             Wyoming has now taken over the responsibility for the communication
             network originally developed by RMP.  Also, through RMP impetus, a new
             record system was adopted in the Big Borh Hospital which is being
             extended to other hospitals in the area.

             The site team was interested to learn about the development of the Nurse
             Physician Assistant Program.  The first registered nurse to be trained
             will practice in the Cambridge, Idaho community which is presently served
             by two physicians and cover a radius of 200 miles.  The Nurses Association
             was active in developing the legal instrument--the Nurses Practice Act--
             which was spearheaded by Doctor John Edwards, a member of the Idaho State
             Legislature.
             Out of 66 physicians contacted personally, and 132 physicians (from a total
             of 198) who returned the questionnaire, 10 expressed the desire to have
             a Registered Nurse Assistant.  Although this would appear to be a low
             figure, the team felt that acceptance of the concept in this area is more
             significant.  Nurses are really doing patient work with only somewhat dis-
             tant supervision.  Also, it was noted that liability insurance covering
             practice activities for participating physicians is continuing without
             an apparent increase or mark-up in premiums.
             Planning discussions are underway with the 'University of Wa;tiingt'on
             leading to participation by Idaho and Montana in WAMT(I,Tishington-
             Alaska-M6ntana-Tdaho).  This experimental program proposes
             regionalization through training by the University of Washington
             School of Medicine of medical students, interns and residents in the




          Mountain States Site Visit Report                 - 8 -                RM   00032


          states of Alaska, Montana and  Idaho.  Communities  will  be  chosen  by  the
          University of Washington, based  on  existing  local  resources  and  manpower.
          In the state of Idaho a series of seminars involving the Medical Association,
          CHP, the Advisory Committee to the State  Board  of  Education,  RMP  and  others,
          is seeking the means for establishing  an  administrative  base  to  relate  to
          WAMI.


          EVALUATION
          While the application did  not give specific details about Evaluation methods,
          the team was unanimous in   the impression that,  under  very  capable  direction,
          evaluation for the program is of  very  high  quality.  The  results  thus  far
          have been.project, rather  than  program  oriented.  Also,  the  team  recommended
          that the assessment of the overall  program  would  be  strengthened  by  in-
          creased participation of  consumer  groups  and  allied  health  representatives.
          Since the evaluation mechanism is quite new,  there  was  not,  as  yet,  evi-
          detce of a strong feedback method to relate program and project evaluation
          to the Regional Aclvisory.Group. It  was  agreed,  however,  that  this  will
          doubtless be a very real part of the  upcoming  reappraisal  of  use  of  reduced
          funds in the forthcoming Triennium.  The  data  presented  to  the  site  team
          is comprehensive  And  indicates  practical  applications  and  Accomplishments
          in a short period of  time.  The  feedback  for  improvement  in  programming
          is receiving attention.  There   is in operation  now  a  computer  print-out,
          a common registration form, a quick response scheme, a satisfactory
          questionnaire, etc.

          WICHE AS THE GRANTEE
          In addressing the question, "WICHE--What is it?", Doctor Bunnell explained
          the  functions  oIf the three  programming  divisions  of  WICH9:  (1)  planning
          and management. systems, (2) mental health, and (3),general "regional"
          programs such as  Regional  Medical  Programs,  student  exchange,  etc.  WICHE
          as the "backdrop" for the Mountain  States  RMP  seems  to  be  a  reasonable
          and functional organizations mainly because WICHE was already regional
          in concept. It was organiz&d  to  serve  an  educational  function,  and  through
          thefaulkner Report, had identified the  need  for  a  'regional'  medical  school.
          Finally, it provides  strong  management  expertise.  WICHE  is  committed  to
          the  spons.orship of a strong Regional  Medical  Program  and  provides  the  MS/RMP
          with an amicable, historical  and  mutually  beneficial  background  for  program
          goals.
          Doctor Bunnell responded to the question of the  future  role  of  IIICHE  in
          Regional Medical Programs with a  statement  concerning  new  thrusts  for  RMP
          away from Continuing Education to new roles, such as development of Health
          Maintenance Organizations.



           Mountain States Site Visit Report                   9 -             RM 00032


           NEVADA AS A SEPARATE REGIONAL MEDICAL PROGRAM:
           This portion of the site visit took place in Reno, the location of the
           new School of Medical Sciences, University of Nevada.  The site team
           had previously identified several concerns about the request from Nevada
           for separation.  These were discussed in a friendly and responsive manner.
           Doctor George Smith, Dean, outlined about eight reasons for Nevada's wish
           to become an autonomous RMP:  Nevada feels it is capable of assuming its
           own leadership role; they need the authority to assume better local control;
           an independent Nevada RMP would decrease intermediate levels of  bureaucracy
           (Washington-Boulder-Boise-Reno); better utilization of their own  facilities
           and personnel would be,possible; more effective coordination of  overlapping
           Regional Medical Programs activities (Intermountain, Mountain States,
           Davis,, Loma Linda) would be possible; development of local priorities
           would be enhanced; as would the development of new relationships with
           WICHE.  The last point was considered somewhat irrelevant to the issue
           of a  separate Regional Medical Program for Nevada.  Indeed, there was
           no real description on the part of spokesmen for the Nevada group of what
           would be done differently if they were independently organized.  The  Nevada
           group appears to be a long way from the development of A concept of the
           necessary organizational structure, objectives, etc., in terms of local
           capability.  The presentation was a most interesting description of edu-
           cational opportunities in Nevada, both at an undergraduate level and the
           new two-year medical school.  However, there was conclusive evidence that
           planning for a new Regional Medical Program has not proceeded very far.
           Neither was there a definition of its role in the new School of Medical
           Sciences.
           Doctor Fred M. Anderson, member of the Board of Regents, University of
           Nevada and Commissioner from Nevada to WICHE, as well as Member.of the
           Nevada SectLon of MS/RMP  RAG, reported that statewide elements favor
           :autonomy as soon as feasible.  He suggested as one possibility, an
           affiliation agreement with WICHE, on an interim basis, to benefit from
           WICHE's expertise in planning, while Nevada continues to plan for full
           autonomy with the University of Nevada as the grantee.
           Dr. Elliott, who represented the State Medical Society, spoke about inter-
           relationships at the state level which could be strengthened through an
           autonomous RMP--the Department cEHealth, State Medical Society and the
           School of Medical Sciences.
           An attempt was made to get an understanding of the "administrative
           stumbling block" which now prevents smooth and workable relationships
           with IJICHE through the existing RMP structure.  it was learned that no
           definite'time has been set for NevAda's separation; the local group
           appears unanimous in its desire to withdraw from the four-state area.
           At the same time, the retirement of Dr. Popma later this year and tied
           recent appointment of Dr. Joseph Deischer as State Director for Nevada,
           may influence the timing of autonomy for Nevada.



         i4ountAin States Site Visit Report       -10-              Rm 00032

         The Chairman of the site team expressed appreciation for the posture
         of Nevada in its flexibility of timing for autonomy  and  its  constructive
         attit ude about a separate Regional Medical Program.  He  referred  to  a
         planning application which would represent the organizational structure
         for such autonomy and outlined the objectives,  which  ideally,  such  an
         application should incude. First, there should  be  a  definitive  design
         for the RMP in terms of.local capabilities and  commitments.  Also,  a  full
         description of a Nevada Regional Medical Program will be  required  by  all
         reviewers and the National Advisory Council.  Consideration must be
         directed toward 611 health interests - professional  and  voluntary  organi-
         zations, hospital interests, desires of practitioners, etc.  All will need
         to be weighed, and hopefully, a "blueprint" for  a  new.Regional  Medical
         Program will emerge.  This will require many months of study and
         preparation.
         The site visitors discussed the "transition scheduling"  in'terms  of  a
         target date for.separation, and the timing factors in line with preparation
         of new applications, review cycles, etc. The  @eam  suggested  that  perhaps
         a small group, which would be representative of WICHE,  MS/RMP  and  Nevada,
         could meet to develop a plan of procedure, which in turn, could be
         presented for consideration of the Review Committee and the National
         Advisory Council.
         The Chairman also pointed out that the split in South Dakota and
         Nebraska was not viewed by RMPS and the NAC as a  precedent  upon  which
         Nevada (or-any other region) could build its  case  for  secession.  Each
         case is a distinct phenomena and with many  readily  apparent  differences.
         Nevada was complimented on its obvious desire   for orderly procedure
         in the steps to establish autonomy.  However,   the need for an organizational
         matrix to stimulate staff inter-relationships  was emphasized in  order  to
         provide an environment for a series of dialogues.  This should include, of
         course, identification of the requirements of-IIICHE as well as give due
         consideration to the needs of all four states.
         Doctor Kevin Bunnell  in  stati-ng the position of WICHE, expressed the
         opinion that all of the points raised by  Nevada:for  becoming  independent,
         are capable of solution.  He also pointed to the necessity of.achie'vin:g
         mutually beneficial resolutions which will have to  be  negotiated  with
         representatives of Reno, Boise and Boulder.

         REDUCTION IN PROGRAM FUNDS
         The site team was naturally concerned about  the  administrative  format
         for setting priorities and decision-making within the present
         budgetary restrictions.  Regional representatives pointed   out that  the
         Executive Committee, working with the MS/RMP RAG,  will  develop  recom-
         mendations for cuts. In turn, the four-state  Core  staffs  will  develop
         their recommendations, and a combination of the two sets  will  be  formed.
         These will again be reviewedty the Executive Committee, and if
         necessary, by each State Advisory Group.  After full agreement, the
         list will be presented to the RAG which has   authority for final
         decisions.




         Mountain States Site Visit Report                    -11-             RM   00032


          The regional priority system  will  be  utilized  in  developing  plans  for
          phasing out, termination, cut-backs, etc. of existing programs.  An
          attempt will be made to  maintain  program  viability  in  all  four  states.

          A number of ec?5nomies can  be  effected  in  travel,  meetings,  elimination
          of RMP funds for  the  Cancer  Registry  after  December  1,  1971,  consolida-
          tion of fragmented training programs below the eight current ones,
          exploration of a variety of ways to assure that the Mountain States Cancer
          Institute would not need to receive significant funding beyond two years
          from now, etc.

          The MS/RMP hopes  to  effect  such  reductions  in  line  with  recommendations
          of the site team, particularly  as  regards  the  design  for  a  transition
          from coronary  care-intensive  care  activities  to  other  broader  concepts
          for RMP, utilizing such  facilities  and  personnel  to  a  maximum  extent.

          -SUMMARY OF FINDINGS AND RECOMMENDATIONS

          1.    The region exhibited expert know how in developing an effective
                network for health planning in this large four-state area.  The
                Regional Director has  been  successful  in  recruiting  and  retaining
                excellent  Core  staffs.  Sub-regionalization  through   the   establish-
                ment of four state  offices,  plus  the  regional  headquarters  office
                in Boise 'although expensive,  is  justified  when  one  considers  the
                significant impact of  this  means  of  distributing  Regional  Medical
                Program activities to  many  communities  of  varying  size  throughout
                the four states4 The  Core  staff  should  be  encouraged  to  continue
                to plan, develop and implement new patterns of health services.

          2.    A real achievement for RMP is the emergence of the School of Medical
                Sciences in Reno, undoubtedly due  to  RMP  influences  in  that  area.
                the next few years will be critical in its development and the
                region was cautioned that RMP has never been viewed as the mechanism
                for support for medical schools or undergraduate training.

          3.    The MS/RMP needs to direct its attention to better coordination
                of Continuing  Education  Programs.  One  means  of  accomplishing  the
                reduction of such fragmentation would  be  by  the  development  of  a
                multi-disciplinary  (involving  all  health  professionals)   approach.
                This should focus on comprehensive patient care instead.of the
                professional disciplines involved, and develop into a team approach
                for continuity of patient  care  as  well.  This  should  afford  a  more
                economical and effective continuing education program, with improved
                utilization of manpower.

          4.    RAG membership needs broader representat on.

          5.    The Mountain States Tumor Institute should attack its needs in
                grantsmanship without further delay, in line with previous details.
                It was agreed that RMP  support  for  this  activity  should  be  limited




          Mountain States RNP Site Visit                -12-            RM   00032

                to two more years.  In developing the Scientific Advisory Committee:
                at St. Luke's, consideration should be given to the inclusion (per-
                haps by means of consultants or sub-committees) of other health dis-
                ciplines, such as nurses, educators, physical therapists, social
                workers, etc. This will assure.tbat planning will be more relevant
                and comprehensive.

          6.    MS/RMP and l@IICHE should attempt to coordinate   the current influx
                of health professionals into all four states.

          7.    There was consensus on the part of the site visitor  t at t e
                mechanisms for  decision-making  are  sound,  well  organized  and
                managed.  Further, the region was advised to apply the same
                principles   a.nd tools,that  have  demonstrated  success  in  order
                to economize on diminishing RMP support.

          8.    The Region has been most innovative in appr   oaches to    solving
                health problems.  Lacking thus far are realistic thrusts in the
                areas of hypertension and kidney'disease'.  These needs should
                be addressed in due course.

          9.  The separation of@Nevada issue was thoroughly explored      with all
                interests.  There was agreement among the visitors that init ation
                of a series of dialogues should now begih-with all parties represented
                with a view to the establishment of meaningful and mutually benefi-
                cial RMP organizations.

          10.   Developmental Component    Approval in amount re4ue'sted      $71,000.
                The region is fiscally soundi mature in management, and has
                demonstrated responsibility in program development and decision-
                making to warrant the flexibility of'judgement and ability to
                direct its own Regional Medical Programs affairs.

          11.   Continuation of Core staff support and all operational activities, as
                follows:




            MOUNI'A,IN STATES RMP                             13                 RM   00032



                                                                             Recommendation

            Project No. and Title                  Reluebt            04 Year         05 Year        06 Year

            Developmental Component                71,000             71,000        $    71,000           71,000
            CORE                                  1,159,109          800,000              850,000        875,000
            #2R-Coronary   Care    Training         148,582          100,000              -0-            -0-
          *#3R-l'umor Institute                    207-,172          200,000              150,000       **50,000
            #5-CE for Health Prof.                 76,177             70,000             70,000      ***50,000
            #6-Tumor Registry                       166,271          100,000              -O-            -0-
            lk7-CE  for  Nursing   (Nevada)        91,271i            70,000             50,000          -0-
            #8-Inhalation Therapy CE               76,068             50,000             50,000           50,000

            #9-Cardiac Care Training
               (Nevada)                            70,737
                                                                      70,000             70,000      ***709000
            #10-Consulting Teams (Nevada)          33,343
            #11-CE  for   Nursing   (Idaho)        89,255             50,000             50,000      ***50,000

            IP12-Coronary   Care   Training
                 (Idaho)                           88$827             60,000             50,000      ***50,000
            #13-CE for Nursing (Wyoming)           77,308             50,000             50,000      ***50,000
            #15-CE for Nursing (Montana)           94,820             50,000             50,000      ***50,000
                    TOTAL                        $2,449,940         $1,741,000         $1,511,000     $1,366,000
                                                                                         *200,000
                                                                                    @l    711,000

            Region   currently    supported      $10873,974




               *For New Projects implementation - $200,000.
              **Tumor,Institute  to  phase   out   in   05-06   years.
             ***Recommend phasing out by 06 year to mak6 these funds available for new
                 programs.


                                                                            RMPS/GRB/5/5/71









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


              NASSAU-SUFFOLY, REGIONAL MEDICAL PRBGRAM         RM  00066   5/71
              19lq Middle County Road                          April 1971 Review Committee
              Centereach, New York  11720

              PROGRAM COORDINATOR,  Glen  E.  Hastings,  M,D.

              This application requests operational status and,funding for the Nassau-
              Suffolk RMP.  Prior to South Dakota's independence starting in planning,
              Nastau-Suffolk was the only one of 55 RMPs still in planning status.

                                         01           02           03         04        t"a

              Core                   $    451,755     490,408     530,043     0       $1,472,206

              #1 Home  Care              95,182       95,260       97,603  $72,448      360,493

              #2 Stroke                  72,111       94,196      118,426     0         284,733

              #3 Pap  Smear              95,956       105,468     106,557     a         307,981

              #4 Rtg.  Med. Libtar       46,860       46,750       48  994    0         142,604
                                  y

              #5  Radiation Rx           27,830       19,085       19,085     0           66,000

              #6 Smoking                 27,910         7,050        0        0           34,960

              #7 Computer Assisted
                 Electr6eardiology        302,632     92,576       58,788     0         453,996
                 & Spir6metty

              #8 Training Community
                 Health Aest's            109,382     67,225       46,860     0         223,467
                 Advocates

              #9 Drug Info. Center        146,316     149,511     i54,019     0         449,846

              #10 Clinical Nurse
                 Specialist              53,762       55,550         0        @o        109,312

              #11 Dial Access            37,525       38,416       39,306     0         1154247

                  .TOTAL               $1,467,221  $1,261,495 $1   219,681 $72,448  $4  020,845

              NOTE:  Indirect costs allowance   is not requested.  Instead, 1M. of direct
                     costs ate budgeted for subcontracting with Stony grook Foundation
                     as fiscal agent.  Fiscal fees budgeted the first year total $130,433,
                     (Coro - $40,747 and 10  proj6cto  -  $89,686).





         Nassau-Suffolk RMP                -2-                     RM  00066   5/71


         SUMMARY OF PLANNING PHASE FUNDING:

              01 (8 months)                02                  Total
              1169-6/70                 7/70-6/71
              $263,01.1                  $350,269            $613,280
         BACKGROUND:  This Region encompasses Nassau and Suffolk Counties comprising
                      100 miles of Long Island east of Queens,  The area was originally
         included in the Metropolitan New York Regional Medical Program.  The efforts
         to begin a separate region began with the formation of  a  Advisory  Medical
         Group in 1967. In June 1968, the Group  incorporated  as  the  Nassau-Suffolk
         Regional Medical Program, Inc. operating within $1.0,000  contributed  by
         eight interested agencies. More than  eighty  organizations  supported  the
         new region in its planning. The Metropolitan  New  York  Regional  Medical
         Program agreed with the two counties that it was  reasonable  that  Nassau-
         Suffolk Counties form a'separate region having  geographic  capability  with
         other major relative organizations, e.g., the Long  Island  Hospital  and
         Health Planning Council; the State Health Department for  CHP;  the  Nassau-
         Suffolk Regional Planning Board, financed by HUD for  planning  in  housing,
         economics and educational development; and the New  York  State  Department
         of.Mental Hygiene. Distance and  transportation  posed  difficulties  in,
         developing vital relationships between the  counties'health  professions  and
                      t- an N.Y. medical centers.  The new Health Sciences
         t e - ero@oli                                                     Center be n
          h  me
         developed at the Stony Brook Campus of SUNY had brought-medical    center
         competence directly to the N-SRMP.
         The developing Stony Brook Health Sciences Center is to include    Colleges
         of Medicine, Dentistry, Nursing and Allied Health; a School of Social
         Work, a Health Sciences Library; a University HosDital; and  a  VA  Hospital.
         Other resources in the region include 41 hospitals, county health departments,
         several specialized research facilities, and the Brookhaven National
         Laboratory.
         The planning application was reviewed by the Review  Committee  and  Council
         in the December 1968 cycle.  Planning objectives:  improvement in the
         delivery of medical services to all people in the  community;  extension  of
         professional education; increased public education and  the  development  of
         more extensive research, particularly in  epidemiology  and  etiology.  The
         Committee believed that the regional assets compensated for  the  lack  of
         specificity in the application    In response to questions raised  by  the
         Committee, the Region named previously unspecified members of the Execqtive
         committee and added 20 non-corporate members to the RAG.  Additional
         information about staffing patterns was  also  provided.  Although  Council
         bad the additional information it shared  the  Committeets  concern  about
         the ROgion's heavy emphasis on computer  and  epidemiological  personnel.
         Support was approved for two years of planning beginning  January  1,  1969
         (01 - $223,256 and 02 - $320,024).
         B       of difficulties in personnel recruitment there  was  little  activity
          ecause
         until the appointment-of the current Program Coordinator on  June  1,  1969,
         For this reason, the first grant period was extended from 12  to  18  months      z@-..






              Nassau-Suffolk 'RMP                                         RM 00066  5/71



              with no additional funds.  In lieu   of indirect costs, the award was amended
              authorizing an increase of $29,755   the first period and  $30,245  the  second
              period for fiscal agent fees.  The   fiscal Agent is  Stony  Brook  Foundation,
              Inc.


              The second  year planning continuation application was reviewed by RMPS
              staff.  Needed refinement of objectives and activities as outlined by
              the Program Coordinator's letter of October 7, 1969 were noted.  Region-
              alized cooperative arrangements and program development had quickened
              with the appointment of a Program Coordinator and subsequent employment
              of sthff.  Staff agreed that satisfactory accomplishments coupled with
              projected activities reflected continuity and movement toward effective
              operational status in 1971.  Of particular interest, was the link witb.
              CHP and the Long Island Health  and  Hospital  Planning  Council.  The  Program
              Coordinator heads both IW and CHP  and  office  space  is  shared.  The  Health
              and Hospital Planning Council is also.considering joining the sharing of
              quarters.

              DEMOGRAPHY AND GEOGRAPHY:






                        Long.,'Isl.and Sound





                                   SUFFOLK



                                                         Atlantic Ocean
      @New
       York






              A) Population:  Nassau County - 1,428,000
                               Suffolk County - 1,011,000
                                                 2,438,000@

                               Urban:   Nassau  -  99.7%
                                       Suffolk  -  77.3%


                               Racial:   Nassau - 97/. white
                                        Suffolk - 95% white


              8)  Land Area:    Nassau - 300  sq.  miles
                               Suffolk -'.922 sq.  miles
                                       1,222





          Nassau-SuffOlk RMP               -4-                 RM 00066  5/71

          C) Facilities: The State University of NY. at Stony. Brook is in  the  process
                         of developing a Health Sciences Center to  include  Colleges
          of Medicine  Dentistry, Nursing and Allied Health Professions; a School
          of Social Work; Health Sciences Library; a University Hospital (60.0 beds);
          and 6 VA hos ital (750 beds).
                     p
          There are 41 hospitals in the region with 35,840 beds.

          D) Health Manpower:
                     3,121 physicians (Nassau - 2106 and Suffolk - 1,015)
                                       124/100,000
                     6,981 nurses (Nassau - 4,143 and Suffolk - 2,838)
                                   280/100,000


          GOALS:
          The long range goals are:  1) To improve the distribution, accessibility,
          volume capacity, cost effectiveness, and quality of personal  health  services
          available to all residents of Nassau and Suffolk Counties; and 2)  To  develop
          mechanisms intrinsic to the health care system which.will permit systematic
          ongoing identification and documentation of unmet health needs and the
          evolution of alternative solutions to meet those needs.
          Immediate goals, as detailed on page 13 of the application, deal with
          innovations in continuing education for allied health manpower, public
          education and cooperative health planning.
          Ob'ectives for the first 12 months are described beginning on page 13.

          PRIORITIES:
          Priorities have been developed and because of their relevance to the projects
          discussed later in the summary.are worth repeating and are appended.
          Protocal for ranking projects by priority is enumerated in section II of
          the appendices. Each project has the potential scoring of 10  to  100  against
          two criteria:  1) where it falls in the Priority List; and 2) its intrinsic
          merit.


          STRATEGY:
          A multiple-leveled program strategy has evolved from the planning process.
          It is based upon NSRMP's general conclusion that many, if not most, of the
          major problems of delivering health services to victims of heart  disease,,
          cancer, stroke, renal disease, and related diseases, are not unique to victims
          of these afflictions, but are problems afflicting the entire health care
          system. Therefore, NSRN? proposes that improving services  for  victims  of
          the categorical disease can beat be done by addressing major flaws  in  the
                           M-itself.
          health care syste






            Naagau-Suffolk R@                 -5-                 RM 00066  5/71


            "The basic program strategy of N-SRMP is to develop mechanisms  within  and
            outside of the health care system to establish and  legitimatize  consensus
            planning as a mechanism for building commitment to change parallel with
            the implementation of needed changes in the health care  delivery  system."

            ORGANIZATION: organizational structure and project review charts are  appended.

            The bylaws provide for two classes of RAG memberhsip, 25-100 corporate and
            20-50 non-corporate. There are three minority ethnic  members  and  twelve
            consumer representatives. The prescribed membership ratio  is  3  corporate
            to 1 non-corporate.  According to the rosters, the current RAG consists
            of 82 members (63 corporate and 19 non-corporate).  The RAG meets every
            three monthso  It has responsibility for approving all contracts and ,
            applications and receiving quarterly reports from officers of  all  expend-
            itures and actions undertaken by the  corporation,  Non-corporate  members
            may not hold office as an officer or member of any Committee' of the
            Corporation or the RAG.'

            The Board of Directors consists of 30 members representing appropriate
            disciplines and/or organizations described in the bylaws.  At  each  annual
            meeting of the members, ten directors whose terms expire are  elected  for
            three years by the corporate members.  The Board meets during at least
            ten months of the year and their duties include managing the  business  in
            the months intervening between RAG meetings. The Board shall  also  submit
            at each quarterly meeting of the RAG a detailed report of the Corporation'*'
            progress during the previous quarter.

            The Executive Committee consists of the four officers of  the  Corporation
            and the Chairmen of the three standing committees of the Board.  The
            Executive Committee shall conduct the affairs of the Corporation  between
            meetings of the Board of Directors.

            The,officers of the Corporation (President, Vice President, Secretary  and
            Treasurer) are elected by the RAG at the annual meeting.  Candidates  must
            be directors.

            There are three standing committees of the Board of Directors.  They  are
            Administrative, Program and Evaluation, and Membership.  Standing committees
            of the RAG:  nominating and aims.  Other committees (ad hoc):  Health
            Information and Communication Systems; Cancer; Editorial and Public Relations,,
            EdutAtion: Finance; Heart; Personnel Practices; Project Ranking; Stroke; Renal
            D196A#e: and 'Respiratory.
            CHP and RKP staff functions have been integrated. There is a  formal  line
            organization for contacts outside of the organization; developing new staff
            activities and relating them to the RAG or its subsidiary group; an  emp  oyee
            accountability and evaluation.  Alternate organizational forms which allow
            for maximum employee participation are used for problem-solving and  technical
            teak performance. Core,tooks are divided into throe caiegoriet.4  1)  organit-
            ition maintenance (41.7% time); 2) planning tAske (38.9%); and 3) project-
            related talks (19.4%).




        Nassau-Suffolk RMP               -6-                    RM  00066   5/71

        Formal geographic sub-regionalizati(Yn is not planned. The rationale  is
        that the region is small. and there are rapid changes in population
        concentrations.
        RELATIONSHIPS TO OTHER HEALTH PLANNING PROGRAMS,
        The major relationship is with CHP. Eighteen members  of the RAG serve on
        the N-SCHP Council and five are represented in executive groups of  both
        organizations. Three CHP volunteer members serve on  the RN? Aims Committee.
        There has been a merger of staffs, as well as Committees on Health Information
        and Research. Negotiatioha are currently under way for a  total  merger.
        There are cross reviews of projects by CHP and RMP.
        N-SRM? and N-SCHP continue to explore merging with the Long Island Health
        and Hospital Planning Council, including office sharing.  Meanwhile N-SRMP
        And N-SCHP review all construction applications to LIHHPC.  Likewise LIHHPC
        staff assist in the review of RMP and CHP proposals involving constructi-op
        and renovations
        RAG representatives also serve on the Suffolk Task Force on Hospitals and
        Health Related Activities.  The Task Forc e. four years old, is to devise
        a long-term master plan for allocating public funds for health.
        The Region is participating by a contractual arrangement with Harvard
        University Center for Medical Care and Health Services Research in A
        multi-regional roject designed to identify  useful  evaluation  criteria
                      p
        and techniques.
        Relationships also exist with the New York State Health Planning-Comission,
        H.E.W. Region II, and the Nassau-Suffolk Planning Commission.
        The application includes a core staff consultative activities list of
        approximately 150 Agencies indicating that cooperative arrangements exist,
        with practically all resources.


        EVALUATION:
        Some steps relevant to both program and project evaluation have already
        been taken.  Several steps will provide baseline data for mea.suring future
        progress: some steps are to increase the.regionts Acceptance and use  of
        evaluation as part of planfting; and some steps have lead directly to project
        proposals and future planning efforts.
        The N-GRMP has studied the evaluation experiences of other  regions,  as
        well as soliciting other regionslcomments on its own approach.  Outside
        consultation is being sought as evidenced by the Regiofib  participation
        in the multi-regional program evaluation through the Harvard Center,











            NAssau-Suffolk
            Regional Medical Program          -7-                    RM 00066  5/71

            PRESENT APPLICATION: Core support is for three  years.  One  project  is
                                  for four years, eight for three years and  two  for
            two years.  A developmental component is not requested.

            Each of the projects received preliminary review and comment  by  staff
            and the appropriate categorical disease, or other ad hoc committee.
            These reviews were made in the light of: a) assessment  of  the  technical
            merits of each proposal; b) the prospects of merger with  similar  pro-
            posals; c) the prospect of extending the  proposals  organizational  base
            so as to develop the widest possible number of "cooperative arrangementsll
            between different organizational groups; d) suitability of  the  project
            for funding under the guidelines of PL 89-239; e) exploration of
            alternative funding sources; and f) potential of-@,the project for supporting
            future planning activities.

            Of the original 41 project outlines submitted for the  development  for
            RMP funding, 16 were withdrawn by the project  authors.  The  remaining
            25 wore reviewed by the Program and Evaluation Committee,  Aims  Committee
            and RAG. RAG final recommendations include considerations by  22  of  its
            sub-ieview bodies.  only 12 projects were approved, one of which was
            subsequently withdrawn by the applicant.  Project numbers represent their
            priority rank order as approved by the RAG November 12, 1970.

            CORE:  The request reflects an increase of about 25%.       Requested
                   Personnel ($302,587) includes nineteen               First  Year
            positions all of which are filled except two.  Pro-         $451,755
            fesdionals include the executive director, two assistant
            directors, two planning associates, one coordinator for planning
            and evaluation, one administrative associate, one health  educator,  one
            systems specialist, three planning assistants, and one (M.D.) coordinator
            for continuing education. The director and one  planning  assistant  are
            paid 50% from RNP funds and 50% from CHP.  Six  secretaries  art-budgeted
            (4 full time and 2 part time - 1107,). The amount of $40,147  (10%)  is
            budgeted for the fiscal agent.
            Core activities in the planning years have included 9 feasibility studies.
            Data collected include available health facilities  and  services  n  @ng
            Island, health training programs, and geographic distribution and
            sociological characteristics of health professionals in  the  region.  Un-
            met  needs have been inventoried and objectives and priorities set.

            objectives for the first operational year: develop  and  secure  funding
            for health projects which incorporate new regional cooperative arrangements
            And address problems of major regional importance;  enhance  visibility,
            utility and credibility of N SRW among both providers  and  consumers  of
            health care; establish mechanisms for regional and  subregional  consensus
            planning and resource sharing both inside and outside of  RMP;  enhance
            the informational data base useful in health planning  decisions;  devi*6
            methods of evaluating N-SM4P's impact upon the health care systeeg








         Naaaau-Suffolk
                                              -8-                       RM 00066 5/7,
         Regional Medical Program
         address directly some of the regions gaps in health care delivery  And  ed-
         ucation through funding of projects in this application; enhance  the
         level of expertise for developing innovative and effective continuing
         education; and further cooperative integration of N-SRMP with the
         activities of other planning and program development agencies.  The work
         plan also includes a description of proposed activities.
           Second year:  $490,408             Third year:  $530,043
         Project #1 Comprehensive Home Care- The project aims         Requested
                                             at improving             First Year
         services to ratients with heart disease, cancer, stroke       $95,182
         and related diseases by seeking solutions to problems
         inherent within the health care delivery sytem.
         The project is related to the Project #2, Stroke Referral and  Evaluation,
         in that both provide mechanisms for'coordinating the services available
         to the chronically ill and the handicapped.  The Rome Care project seeks
         direct resolution to 'Substantial organizational marketing problems in
         the delivery of home health services, while the Stroke  Referral  and
         Evaluation project serves principally as a patient protection  device
         coordinating care of chronically disabled persons across all levels of
         care (hospital, ECF, home care, ambulatory care, nursing  home).  The
         Stroke Referral and Evaluation Program thus will provide a data  base
         from which both formative and silmmative evaluation of the Home  Care
         Ptogram's effectiveness in improving patient care may be assessed.
         The proposed activities of Phase I of the Comprehensive Home Care
         Project are to identify and seek feasible resolutions to the existing
         market constraints and organizational constraints limiting the delivery
         of comprehensive home health services.  PhasevII and III will establish
         financially self-sufficient administrative mechanisms  through  which
         home health services in Nassau and Suffolk Counties may be coordinated
         and int egrated; through which administrative, cost accounting, and patient
         records keeping procedures may be standardized; and through which
         inefficiencies, duplication of effort, and disproportionately high
         administrative overhead costs may be reduced.  Phase II involves pilot
         testing individual administrative mechanisms in selected areas and/or
         agencies and Phase III involves extension of successfully piloted
         mechanisms to all participating agencies. The  project  will  provide
         an organizational planning mechanism and a systematically obtained data
         bast from which the level of need for ancillary home health  services  may
         be documented and those services added in a preplanned, integrated
         fashion.  The program represents the next step in the integrated planning
         and development of Home Health Services in the Nassau-Suffolk  area  which
         has grown from the Nassau-Suffolk Task Force on Home Health Services.
         The project addresses the problem of delivering home health services in
         a more cost 11 -effective manner, and of improving the availability,
         accessibility and volume capacity of home health services available to
         the residents of this region.  These are priority I concerns of the Region.









             Nassau-Suffolk
             Regional Medical Program           -9-                      RM 00066  5/71

             The project includes an evaluation component. Also  included  are  letters
             of endorsement from 23 agencies.  If the project succeeds in establishing
             administrative means to permit greater cost effectiveness  in  delivering
             home care, it is anticipated that  those  administrative  structureswill
             continue indefinitely as a legitimate overhead expense  for  participating
             agencies, with the cost of the expense defrayed through conventional
             third party payments.

                 Second Year:  $95,260     Third Year:  $91',603   You-rth Uw:  $72$448

             Project #2 Stroke Evaluation and Referral- This project         Requested
                                                        is designed          First.Year
             to improve access to coordination of the community              $72,111
             resources available to stroke victims residing in Nassau-Suffolk
             Counties and their families. It will further document  areas  in  which
             needed services are not available or accessible and the  reasons  behind
             lack of Accessibility to existing resources.

             The project will provide:  1) a service function' by coordinating
             available resources to the benefit of stroke victims; 2)  an  ongoing
             planning function through identification of existing "gaps"  in  services;
             3) an evaluative function through sequential reassessment of the functions
             abilities of stroke victims; 4) an educational function  through  identi-
             fying areas in which informational deficiencies of  health  professionals
             may,hinder the appropriate use of community resources in dealing with the
             problem of stroke victims and their families and through   Assisting  in
             the development of "stroke census" in community hospitals; and  5)  a
             research function through the identification of  social,  therapeutic
             and biological determinants of successful rehabilitation.
             The project will pursue these objectives by augmenting an existing
             centralized stroke registry by instituting A system for more rapid
             identification of stroke victiz&s. by providing periodic assessment  of
             the functional capabilities and health service needs of  stroke  victims
             and providing a referral mechanism to insure that contact  is  initiated
             between each stroke victim and the agency or practitioner  with  skills
             relevant to each victim's needs. The project staff  will  also  provide
             a direct educational service by assisting co     ity hospitals in the
             organization and operation of "stroke teams."'
             Measures of the effects of therapeutic intervention, social  factors,  and
             biological determinants upon the rehabilitation potential  of  stroke
             victims will be measured in terms of death, disease, progression
             disability, social disruption and professional and  family  satisfaction
             with both the services provided and the rate of reha i  tat on.

             At the end of the third year of RMP funding, if successful, the  program,,
             will be continued through a combination of local and state funding sources.
             If the project proves to be unsuccessful, it wtil be discontinued.







         Nassau-Suffolk
         Regional Medical Program              -10-                      RM  00066  5/71
         Its high priority lies in that it  addresses  the  problem  of  improving  the
         coordination and integration of  existing  services  to  a  particular  category
         of patients with important therapeutic service needs (a- Pkiority I problem).
         It is aimed at improving access to  available  services  (also  a  Priority  I
         problem). It aims at  improving  the  coordination  of  home  health  services
         (a Priority II problem).  The present project builds upon a strong base
         of acceptance among the laity, among the physicians, among voluntary
         agencies and among health facilities, previously established through
         the.existing stroke registry.
         The project contains the potential  for  expansion  into  a  regionwide  patient
         referral and evaluation network for victims of all chronic diseases.

                                                                    e Care, in that
         The program is related to project #1, Comprehensive Hom
         many of its  patients will at one time or another be referred to one or
         Mort home health agencies.
         The project is also related  to  the  proposed  educational  resource  designed
         as a core staff activity, in that it will provide data regarding educational
         needs of health professionals.  It   will  also  provide  information  regarding
         needed additions to the Dial Access Lecture Program.
             Second Year:  $94,196               Third Year:  $118,426
         Project #3 Development of Pap Smear and Breast Examination            eques   ed
                    Para-Ptofessional Personnel- The purpose$of this          First Year
         project are twofold: a) to recruit, train, introduce and               $95,956
         demonstrate the usefulness of.a  new  type  of  paraprofessional  health
         worker in the Long Island community; b) to provide mechanisms for
         earlier treatment of uterine and breast  cancer  among  high  risk,  low
         income populations through  improvements  in  case  findings,  public  education
         and Accessibility to diagnostic services.
         For each of three years, seven  residents  from  a  low  income,  predominantly
         black community will be recruited and  trained  in  the  techniques  of:
         1) procuring specimens for  Papanicolaou  examination  by  the  direct  cervical
         scope ttchnique; 2) obtaining  Papanicolaou  specimens  by  the  vaginal
         irrigation technique and 3)  instructing  other  residents  in  the  techniques
         of self,breast examination.
         The newly trained health worker will elicit public participation in the
         program by: 1) direct door-to-door personal contact; and 2) public
         appearances at community meetings.
         Five of the newly trained health workers  will  remain  in  employment  at  the
         Martin Luther King Neighborhood  Health  Center  in  Wyandanch,  the  training
         and diagnostic center. Those  workers  trained  during  the  second  and  third
         years will be employed at either Public Health D6paitments and/or voluntary
         health facilities in the region.








            Nassau-Suffolk RMP                                          RM 00066  5/71

            Followup care and definitive treatment of patients found to have examination
            abnormalities will be provided through the Martin Luther  King  Neighborhood
            Health Center and Good Samaritan Hospital.

            Its high priority ranking is based upon the  following  considerations-
            1) it is aimed at improving accessibility of a highly needed  service  to
            a low income, high@risk target population lacking access to  the  service
            (Priority I); 2) it aims at improving the cost-effectiveness of health
            care delivery by delegating a technical skill normally performed  by  a
            physician to a non-professional worker (Priority I); 3) it  provides  entree
            into the health careers for disadvantaged recruits (Priority I).

            It is also reported that the project's site is important as  the  expanding
            population of Suffolk County will probably promote rap id assimilation  of
            newly trained health workers. The project blends with  the  Suffolk  Health
            Department'6 plans to extend the number of its ambulatory  care  facilities
            to five low income target areas over the next five years.

            The project relates to the health manpower development  program  presently
            being developed by RMP-CHP staff and Labor Department officials,' local
            educators and health industry employers.

            Although reducing mortality from uterine and breast cancer  is the  nAjor
            Ain of th e project, this goal will not be meagureable due totthe  lack  of
            unreliable data and the short project tenure.  The project will be evaluated
            in terms of achieving @ projected number to be trained  and  screened.  Two
            thousand women will be screened each year for uterine cancer and  will  have
            learned self-breast examination.  Fifteen  paraprofessional  health  workers
            will be trained and it is anticipated that     v    rem& n emp oye    n   te
            health field after termination of the project.

                Second Year-  $105,468            Third Year:  $106,557

            Project.#4 Reitional Medical Library Service and Training            Requested
                      This project addresses the need to improve the             First Year
            availability, quality and techniques for use of medical library       $46,860
            services in the region.  It involves four major objectives and
            areas of activity:
             1) the establishment of both in-service and collegiate training
                programs in the region for a new category of health mnpower,
                to be called Medical Library Technician;

             2) the establishment and upgrading of library resources, and services
                available in (and to) all community  hospitals  In  the  Nassau-Suffolk
                region;

             3) the development or expansion of hospital  committees  charged  with
                continuing responsibility for hospital library and educational resources
                and services;

             4) the establishment of a functional regional  educational  library  and
                information network among all health institutions for  the  purpose  of
                securing optimal availability and use of regional resources.







                                           -12-                                066  5/71
           Nassau-Suffolk RMP                                            RM 00
           This project will involve all of the  hospital  medical  libraries  in  Nassau
           and Suffolk Counties, as well as the libraries  of  the  two  county  Medical
           Academies, and the library of the Health Sciences Ce ter, S.U.N.Y. at
           Stony B-i6ok ' (whe-ke project staff will be locate(i).'-
                      31
           The project addresses the Priority I area  of  concern;  the  more  efficient
           use of organization and personnel resources through improving the level
           of resource sharing.
           The project includes  an evaluation  component.  The  Department  of  Library
           Sciences of the Health Sciences Center of SUNY at Stony Brook,, the grantee,,
           will assume responsibility for continuing the activity after cessation of,
           the grant.
              Second Year:  $46@750                  Third Year:  $48,994
           Project #5 Computerized Radiation Therapy Treatment Planning         Requested
                      Service- This project proposes to develop                 First Year
           a technical service providing Computerized Radiation                   $270830
           Therapy Treatment Planning which can be utilized by hospitals
           of all sizes and by private medical offices concerned with radiation
           therapy planning in addition to the major institutions where it is now
           available.


           Nassau  Hosp
                      ital, Department of Radiation Therapy, will function as the
           central station for the project, receiving proposed treatment plans
           from participating hospitals or private offices by telephone or telecopier.
           The information will be reviewed by a physicist for the purpose of program
           development by a computer.  Simple programn will be imediately run by
           the Nassau Hospital computer; complex  programs  will  be  sent  by  messenger
           to Grilmnan Data Systems. The completed program  is  to  be  returned  to  the
           sender within 24 hours if by telecopier, or three days if by mail.
           Experience with the development of the technical phase of this program
           and the functional relationships  which  are  developed  among  the  partici-
           pating institutions will determine the future of the program.  It may
           remain limited to technical service or it may become a stepping stone
           towards a clinical oncology program.
           The priority given to this project  was  based  on'it  meeting  the  following
           needs:
           (1)' Priority I - Increase efficiency, coordination, cooperation, resource
               sharing and better referral between existing health services,
               professionals and agencies;
           (2) Priority II - develop a shared accessible, exhaustive, and continuously
               current regionwide health information system composed of manpower
               data, availability of health service, financing data and patient-
               related information; and
           (3) Priority III - improve the level of technical sophistication of
               available services.







               Nagsau-Suffolk R14P               -13-                        RM  00066  5/71

               The project is related to the development of   a   regidnwide   comprdhensive
               cancer program as is the Pap  Smear  and  Self  Breast  Examination  projecti
               it aims toward the evolution of  a  regionwide  health  information  system
               as do the Home Care, Stroke  Referral  and  Evaluation,  Regional  Library,
               Computerized EKG and Spirometry, and Drug Information Projects.

               It is also designed so as to  reveal  professional  educational  deficits  in
               the area of Radiation therapy and thereby is  'related  to  the  cord  con-
               tinuation education development activity-

               Parameters to be evaluated include the extent of utilization of the
               project sdrvides and the projects direct result on patient care.
               It is anticipated that the project  will  become  self-supporting  by  the-
               participating institutions' purchasing its services.
                   Second Year:  $19,085             Third Year:  $19,085
               Project #6 Smoker's Withdrawal Workshop -'The@purpose               Requested
                          of this demonstration program is to decrease           First  Year
               the prevalence of cigarette smoking in Nassau and Suffolk             27,91
               Counties.  It aims at preventing the occurrence of syWtonatic
               heart disease, carcinoma of the lung, chronic obstructive pitimonary
               disease, arteriosclerosis obliterans$  carcinoma  of  the  urinary  bladder
               and other pathological  conditions  Associated  with  cigarette  smoking.

               The project proposes the institution  of  a  series  of  "Smoking  Withdrawal
               Clinics7. The clinics  would  incorporate  the  previous  experience  of  a
               wide variety of similar  efforts  nationwide.  In  addition,  a  number  of
               principles drawn from the literature  on  behavior  modification  would  be
               utilized which have not  been  incorporated  into  previous  anti-smoking
               programs.  The format was pilot tested for logistical feasi       ity   n
               June and September 19.70.

               observation and curriculum development  personnel  will  participate  in  all
               sessions. Their function will  be  to  observe,  in  detail,  what  happens
               during the course of each session, and to make correlations and evaluations
               in relation to specific techniques  applied  and  the  observable  results.
               The observation and curriculum development personnel will meet with those
               conducting the course along with  the  participants  to  determine  which
               techniques are most  productive  and  which  are  not.  Succeeding  workshops
               will thbn be altered as new experience  is  gained  through  the  results  of
               the ongoing *valuation conferences.

               Participants will come from two basic  sources:  (1)  self  referrals;  and
               (2) referrals from health professionals, institutions, and strvicesag W ies.

               Self referral is to be promoted by the Tuberculosis and Restiratory D sease
               Associations, the Cancer  Societies,  the  Heart  Associations,  both  County
               Health  Departments,  and,the  participant  hospitals.  Public  relations
               Activities will include placing of posters in    public  places,  radio  spot




             Nassau-Suffolk RHP               -14-                        RH 00066   5/71
                       ts, newpaper releases and flyers distributed     in participant
             announcemen
             hospitals.
             Physician referral is to be encouraged by circulating flyers to all
             physicians in both Nassau and Suffolk Counties 30 days prior to each
             clinic.  Special notices will also be sent to Department of Inhalation
             Therapy and Chest Service in hospitals, physicians working in Chest
             Clinics of Health Departments, Directors of Medical Education and Nursing
             In-Service Directors in all hospitals.
             The reason for the project ranking is that it relates to disease prevention
             and improving the availability and accessibility of a service, both
             Priority I concerns of the N-SRM.
             RNP funding is to cease after eighteen months.  If the program proves
             effective, the individual hospitals with modest support f   rom the  TB  and
             RD Association, will continue similar programs.
                Second Year (6 months)' $7,050        Third Year:  -0-
             Project #7 A Regional Approach to Computer Assisted Blectro-          Requested
                       cardiography and Spi@o@e                 - This             First Year
             project proposes developing the  cap               0f the              $302,632
             region's hospitals to administer computerized EKG's and spirogramn.
             only hospitals with both in-patient and out-patient facilities will
             be selected.  The project anticipates that 40,000 patients of all races,
             incomes and levels of treatment will be tested.
             The goal of the project's first year is to prove that this technique
             is reliable and feasible as a screening  tool  and  as  a  routine  hospital
             test.  The hospital environment provides the built-in referral mechanism
             necessary for proper patient treatment and validation of the computer
             programs results.  Simultaneously,  the  project  will  bollect,  store  and
             analyze the demographic data.                          -u 'i g' '- 'i-iEaticTiifd "form,
                                             The data gathered by  s n  a
             -An lie' -i-h-aioid' by the participants, as well as 'used f r further planning.
             ,c                                                     0
             Once the techniques have been proven, the long-range goals of the project
             are to add additional computerized diagnostic tests and to expand the
             collection of shared data outside the province of the specific tests.'
             Consequently, this project forms  the  basis  for  a  hospital-based  multi-
             phasic screening center and a regional data bank.
             The proposal addresses six health priority items established by the
             N-SRNP. Three of these are:  (1)  improving  the  availability  of  services
             by providing techniques for the consumer which do not exist at present;
             (2) improving the accessibility of  services  both  in  terms  of  geography
             and affordable costs; and (3) insure continuity and coordination of services
             by continuing the Task Force Committee for future program operation.
             Evaluation areas include: Physicians ancrhospitals       use of and
             satisfaction with the system; cost  benefits;  use  of  screening  data  for
             planning; and-further development to include additional tests.






            Nassau-Suffolk RKP                  -15-                        RM 00066 5/71

            It is anticipated that after three years, the hospitals will ass,---
            financial responsibility for the EKGS,  spirograms  and  data  processing.

                 Second Year:  $92,576               Third Year:  $58,788

            Project #8 Curriculum Development for the Training of CommunjU         Requests
                       Health Assistant and Community Health Advocates             First Year
            This project addresses the problem of designing a structured            $109,382
            educational curriculum for commity health aides and commuity
            health advocates, based upon a preliminary task analysis of the     functions
            Actually performed by such persons employed in Suffolk County.

            The training program introduces a two-stage  "career  ladder"-in  that  those
            personnel demonstrating the highest level of proficiency as community
            health aides will be selected for  training  as  commmity  health  advocates.
            Further career advancement beyond  the second stage is the subject of on-
            going planning between the Suffolk County C  ommunity College, Suffolk E.O.C.,
            Suffolk Department of Public Health and the Health Sciences Center, S.U.N.Y..
            at Stony Brook.

            The aim of the program is to formalize the  training  of  underemployed  low-
            income cow=ity health workers, so as to provide a more stable and better
            defined pathway into the health professions for such workers.  The purpose
            of defining the training program and the skill  level  of  such  employees
            is to demonstrate the relevance of their experience and training to the
            functions performed by health personnel  working  at  higher  levels.  The
            Health and Family Planning unit of the Economic Opportunity Council
            of Suffolk and the Suffolk County Department  of  Health  have  budgeted
            for positions in this new category of health manpower.  In ad    dition,
            the 12 Readstart centers and the several Day  Care  centers  in  Suffolk
            County are also planning to utilize this category of health manpower if
            the proposed training program is successful.  The Comunity Health Assistant
            program graduate will also find job opportunities  with  upward  mobility  in
            the hospitals of Suffolk County.

            The project relates a Priority I problem identified  by  N-SRNP,  to  improve
            the effective utilization of the skills of health workers.  Its major
            thrust, however, is to build an improved access pathway into the health
            services professions for unskilled  and  underemployed  residents  of  the
            aria. If successful, the curriculum design might  serve  as  a  Model  for
            Similar training programs. Demonstration  of  specific  skills  by  graduates
            of this program might enable existing educational programs and institutions
            to modify the length of formal instruction required for Licenses Practical
            Nurse certification or certification in other health occupational categories.

            A team consisting of representatives of  Suffolk  County  Community  College,
            Suffolk County Department of Health,  Economic  Opportunity  Council  of






                                          -16-                      RM 00066 5/71
         Nassau-Suffolk RMP

                                         a of the enrollees and the consumers, a
         Suffolk, R.]K.P., representative
         representative of the Division of Allied Health Professions at the
         S.U.N.Y. at Stony Brook, and outside consultants as necessary,  will  have
         the responsibility of ;ngoing, periodic and concluding evaluation of
         the project.  The main objective of the evaluation team the first year is
         to test the effectiveness of the core curriculum in  relation  to  performance
         of the Community Health Assistants.  Modification of the curriculum during
         the training period will be made when the need is indicated by the evaluation
         team.  Evaluation tools are described in the narrative.

         RMP support is requested for three years, after which  the  training  programs
         are to be funded through M.D.T.A. and local resources.

           Second Year:  $67,225                 Third Year:  $46,860


                                                                          Requested
             Project #9 - Regional Drug Information - The objective      First Year
                          of this project is to establish a regional       $146,316
             drug information system which will. allow participating
             hospitals to collect, correlate and learn from adverse drug reactions.
             On the basis of the collected data and its analysis, the project would
             then attempt to perform an ongoing educational activity for participating
             hospitals, for hospitals generally in the region, for  nursing  homes,
             community pharmacists and physicians.

                                                                                         c
             A network of communications services will be developed to include eiectroni
             communicating devices, sub-regional meetings, newsletters;  monthly  work-
             shops for participating hospitals'and a publicity program to incl de radio
             and/or television.

             Mercy Hospital, having developed a diversified drug program over four
             years, will serve as the focal point.  It is anticipated that the initial
             seven participating hospitals will be expanded to a regional network.

             The project addresses priority III relative to continuity and coordination
             of service, in addition to development of communication  linkages  and
             cooperative arrangements.  The project will al.so be relative to improving
             the quality of care.  The project also addresses priority VI - research
             and information deficienc es.

             The project director and his staff are to evaluate the program semi-annually
             and submit annual, reports to participants, interested individuals  an
             RMP evaluation criteria are described.

             It is anticipated that the participating hospitals will -assume  financial
             support of the project after three years.

             Second Year                                                Third  Year

             $149,511                                                   $154,019






          Nassau-Suffolk RMP                -17-                   RM 00066 5/71

                                                                           Requested
              Project #10 - Clinical Nurse Specialist in a Small General   First   Year
                           Hospital.  The purpose of this project is to      $539,762
              explore the impact of the role of a clinical nurse specialist
              in a small general, non-profit community hospital with an affiliated free-
              standing health center.  The concept of the "Clinical Nurse Specialist"
              as a practitioner, role model, supervisor of patient care, counselor-
              resource person, teacher, coordinator, change agent and researcher,  will
              be implemented to demonstrate that this practice will enhance the quality
              of nursing care.

              One unique contribution of the study could stem from the continuum of
              care for the socially and economically deprived patients who could be
              followed through the health center.  The clinic I,n roe. sD-ec-@@    Sued
              function in both the hospital and health center as the needs of her
              specific patients arose. She would be a role model to the nurses  in  the
              hospital, health center, and community for coordination of services,
              This study could determine if the clinical nurse specialist's role should
              become an integral part of the hospital structure in the near future.
              @it would also determine if, through involvement of other nursing adminis-
              tratort in the surrounding community hospitals through workshops, con-
              ferences, newsletters and publicity, interest in the clinical nurse
              specialist's role can be stimulated and positions opened up.
              The project addresses five of the six problem areas identified by the  ly:
              Program and Evaluation Committee of the Regional Advisory Group, name
              accessibility (Priority 11); continuity and coordination (Priority  III);
              quality of service (Priotity IV); efficiency in provision of service
              (priority V); and research and information (Priority VI).

              Evaluation will be accomplished by the project investigators and a
              committee of consultants.  Methods focus on change in hospital staff
              response to the clinical nurse specialiet's role and patient care.
              Good Samaritan Hospital, the applicant organization, will provide  future
              funding if the project proves ef ective.

              Second Year                                             Third Year

                $55,550                                                $ - 0 -
                                                                        Requested
              Project #11 - Nassau-Suffolk Dial Access Lecture -        First Year
                            The Dial Acess Lecture Project is designed   $37,525
              to taip into and share an existing Dial Access Lecture program
              already in operation in Central New York RMP region and Susquehanna Valleq
              RMP region.  The activity will serve the goal of increasing the continuing
              educational opportunities for the health professionals of the Nassau-
              Suffolk RMP region, thereby improving the quality of health care  in  the
              region.  The project's major costs are for telephone services.  The project
              will supply lecture services for both physicians and nursing personnel
              in the region by utilizing a WATS line.




         Nassau-Suffolk RMP                    -18-                    Rm 00066 5/71
              The project proposes to extend the scope of existing    services by   upplying
              current and frequent updated library references upon    request.  The existing
              program will be modified slightly to improve its.function as a source for.
              identifying practitioner's perceived educational needs.
              The project aims at improving the quality of health care (Priority III)
              and attempts to do so by providing access to a previously established
              Dial'A:ctess TA,cture Program.
              A second attraction of the dial lecture project is its apparent enthusiastic
              popularity among the region's practicing physicians.
              Data obtained through the Dial Access program about physician perceived
              educational needs might provide useful input into the Core Staff Educational
              Development service.  Information gathered through the Stroke Program,
              Radiation Therapy Planning Program, Computerized EKG and Spirometry
              Program, Drug Information System Program, and the Regional 14-brary Service
              Program would all be useful in defining possible subject material for
              additional tapes.
              Evaluation includes determination of the utilization of the a
                                                                                yotem, users
              satisfaction and querying the Regions health leaders.
              There is no provision for continued support-of this project after three
              years.
              Second Year                                                     Third Year
                $38,416                                                        $39,306






                                                                      NA89AU-SUFFOLK        REGIONAL        MEDICAL        PROGRAM
                             I.anninR        Phatie              Funded                               I A                             Reauest             19.-
                             p                                                                at'on"        "'C"t'o"                  1        467.221
                         @01           111/69-6/30/70          $263,011              01   7  1 71-6    30     72
                         '02           7/l/70-6/30/71           3@O@769              02   7/l/72-6/30/73                              1,261,495
                                                Total          $613,280              03   7/l/73-6/30/74                              1,219,681
                                                                                     04   7/l/74-6/30/75                                        72,448
                                                                                                                         Total             $4.0020,845


                                                                           PROPOSED        01        OPERATIONAL                 CO@tP@.FNTS BY TYPE OF ACTIVITY
                             CiX4POI.E,%TS.BY DISEASE CATEGOIZY                           COMPONENTS
                                                                          -co     e      $451,7                            TRAINING    AND     EDUCATIO4
                       EART                                                       r           55
                                                                                                                                                         6
                             0    Projects          1                                                                               Projects         42le55.
                                                                                                                                  Total $S
                             Total    $S        302    632                                                                                             29
                                                                                 @l Home      Care                                %   $S
                             %   $s                 21%
                                                                                                                                 Approved/unfunded
                                                                                  $95,182
                                                                                                                                 Disapproved


                        CANCER
                                                                                  2SCroke-
                             0    projects          2                             $721,IIL
                                                                                                                                                     TIENT CARE
                             Total    $s        123,786                                                                    DE!40';STFATIC,4 OF PA
                             %   $S                 8%                                                                              Projects             5
                             Approved/unfunded                                   @3 Pap      Smear                                Total $S           593,711
                             Disip        rd@ved-                                 $95,956@                                        %   $S               40%
                       STitOKE                                                                                                   Approved/unfunded
                                                                                                                                 Dis@pproved
                                  Projects
                                                                                 #4 Regional   Med.
                             Total    $s        72,111                            Library
                             %   SS                 5%                            $46,860
                                                                                                                           RESEARCH          DEVELOPMENT
                                                                                 #5 Radiation
                                                                                                                                  4 Projects             0
                        KIDNEY                                                    $-279830
                                                                                                                                  TotAl $S               0
                             4    Projects          0                                                                             %   $S                 0
                                                                                                                                 Approved/unfunded.
                             Total    $S            0                                                                             sapproved
                             %   $s                                              #6 Smoking                                      Di
                                                    0
                                                                                  $27,910


                       RET.ATED     DISEASES                                    -#7 Computer
                                                                          ElectrocardiologY                               ADMINISTRATION        @NNING
                              -1    Projects        0
                              Total SS              0                             $302,632
                                                                                                                             # Projects              core
                                 SS                 0                                                                        Total    SS        -@51 755
                                                                                                                             %  $S                     31%
                                                                             #8         Train'g                            Approvc,t/unfunded
                                                                          @unity              Health Asate                 Dlsappr'oved
                       ISUI,'fiCATEGORICAL
                                                                                  .,$109,382
                              if   Projects'        7
                              Tot3l $S          516,937
                              % Ss                   35%                          Drug l@fo.-      Ctr.
                                                                                  $146,316


                       CFI;e'RAL
                                                                              10 clinical Nurse
                              9  Pro   c                                            -Sp6cialist
                                       j@;ti    'Ore
                              Total             451 ,755           1  .           $53.76
                              % ss,                  31%                                      -
                                                                                                          .    I   I
                                                            I    I          #fl    Dial     Ae.ces's
                                                                          I'      37   5@2           _       -1                 RMPS/GRB-311171
                                                                          I
        I*




                                                -20-


                              NASSAU-SUFFOLK REGIONAL MEDICAL PROGRAM
                                           PRIORITY LIST


                                            Priority   I'
                                              (Urgent)

            1.  Act ivities aimed at increasing accessibility  of  health  care  services,
                especially in relation to specific population subgroups currently
                lacking access (e.g., the poor, the near poor, the elderly, the
                disabled, migrant laborers).
            2.  Activities aimed at increasing health manpower availability or
                improving efficiency of manpower utilization.
            3.  Activities aimed at  increasing  efficiency,  coordination,  cooperation,
                resource sharing and better referral between existing health services,
                professionals and agencies.


                                            Priority   II
                                              (important)
            1.  Activities  aimed at innovative improvements  in professional continuing
                education.
            2.  Activities  aimed at developing a shared accessible, exhaustive, and
                continuously current region-wide health information system composed
                of manpower data, availability of health service, financing data and
                patient-related information.
            3. Activities aimed at  instituting  health  measures  presently  unavailable
                in Nassau and Suffolk Counties.



                                           Priority   III
                                              (Necessary)

                Activities aimed at improving specifically those health planning
                mechanisms which are presently weak.
            2.  Activities  aimed at development of new rehabilitative  and  home  health
                services.
            3.  Activities  aimed at improving existing third-party financing mechanisms
                for  direct services.
            4.  Activities  aimed at innovative improvements in lay health education.


                                             Priority  IV
                                              (Useful)

            1.  Activities aimed at improving the bed-to-patient ratio  of general
                care And ECF beds, or promoting their more efficient utilization.

            2.  Activities aimed at improving the level of technical sophistication





                                           -21-


          3.  Activities aimed at reinvolving all physicians lacking hospital
              affiliation @ack into the mainstream medical milieu.


                                          Priorit_y V
                                          (Relevant)
              All other activities falling within the framework of PL-89-239,





                                                                                              -22-



                                                                              ORGANIZAI'10.'@AL STRUCTURE
                                                                                                   .4         'r
                                                           NASSAU -SUFFOLK  FIL-GIO! AL N, -DICAL PPIOGRAM,  INC.






                                                                                     Regionil Advisory Group
                                                                           (Corporate & Non-corpol'ate' t%4emb,.,rsiiip)





                                                                      Nassau - Suffolk RiviP
                   Stony        Brook                        Incorpoiale(i     (Corporlie      IVicinbcrsliip)'
                     I-'otiricf3ticin
                  (Fiscal      Agent)


                                                                                                                    Aims,!nd
                                                                                                                                         Noiiiinnting
                                    Prograin               Board of                                                 objectives           Conirnittee
                                      and                  Directors                                               Conifnittee
                                 Ev3luation
                                 Coinr-rtittee




                                                Heart
                                             Committee




                                               Cancer                                             in;)nce
                                             Coii)niitic-c                                            'ninittee



                                    -           Stroke                                                Personnel
                                             Committee                                            Coniinittc,.,



                                    -        Renal Dise@c                                        By        Laws
                                             Conimitt,@e                                            Comiiiittee



                                             Education                                         Mer   nbersliir)
                                    -
                                             Conimittce                                             Coi-nmittee


                                             Respir@itory                                     Editorial  -.Ilcl
                                    -          Disease                                      Fulilic fl,(!I:iti'ons
                                             Coinmittee                                          Coo-,)il)ittee



                                        llealili Infoi-n-,-ition
                                    - ;and Co.,iinitj;-!ications
                                             Coinlili',tcc











                        F. IA, P
                     +   CHP

                                                                                 TABLE   OF ORGP-.@IIZATION
                                                                                         R@'tP/Cl-'.P



                                                                                 Executive Di,-e@-tor
                                                                                                   +





                                                                                                                                             Administrative Associatf
                   Coordinator for                                                                                                                         I p i n
                                                                                                                                                        Gi
                               ,,id 'EvalLatior,-                                                                                            - - - - - - - - - - - -
                                                                                                                                                           -ve Assistanl
                                                                                                                                             ACni n i s.LraL I
                                                                                                                                                        Surey +
                           .Beckman
                                                                                                                                             iecret6rial/Clerical





                                                                                                                                              Assistant Dir6ctor
                   'MIssistant  -Director                                       Assistant Dire@r
                                                                                                                                                       Europe +
                                                                                         Kress

                   -----------                                                                                                                -----------
                   Planning Assistant                                                                                                         Planning Assistants
                             'I) e I  +                                                                                                               Students    +.




                  ?1.3rinir.g Associate                    ilealtii E-@'uc-itor                        Education Specialist                  Planning      Associate
                          Fari i I ton                          Miller                                         (unfilled)                            Page
                                                                                                                                             S- -  T@s  Tp7eci-alist
                                                                                                                                              yst
                   -Fl@nin-g-As-si-s-t-an-t-               PI Tn n-i T@s s I-S -Fa7n t                                                                Roth
                           Fistiel  +                            Alson
                                                                                                                                             Planning      Assistant
                        Librarian
                                                                                                                                                   Marcus
                            We,ize +




                                                                (A Privileged Communication)



                                SUM.,NP,Y OF REVIEW AND CONCLUSION OF
                                    APRIL 1971 REVIEW CO,@;iIITTEE


                              NASSAU-.SUFFOLK RLGI07iiAL MEDICAL PROGRAM
                                         RM 00066  5/71


                          FOR CONSIDERATION BY 14AY 1971. ADVISORY COUNCIL


             RECOri,n4ENDATIO@l: Approval for operational status for three years with
                               the following conditions:  1) that the Region obtain
             the services of  an outside consultants to assess the current otganiza-
             tional structure including CHP-R@T relationships; 2) that the concerns
             of the reviewers be communicated to the  Region;  3  that  the  second
             year continuation application be reviewed by Committee and Council. and
             include a site visit; and 4) that the level. of funding be increased if
             significant progress has been nchieved  during  the  first  ycar.  The
             Committee al.so recommends Council policy statement on us@e of    PS funds
             for   computerized EKG and spirotictry (Project i,!-7).

             The Committee recommends approval of the  amount  requested  for  core
             activities:  01. - $451,755; 02 - $490,408; 03 - $530,043.

             For projects; $1,01-5,466 is requested the first  year,  $171,087  the
             second year, $689,638 the third year and $72,448 the fourth.  The
             reduced amount of $378,000 is recommended each year for three year.-,.

             The total requested and recommended is as follows:

                                                          Direct Costs
                  Year                               sted              Recbmmei)ded

                   01                            $1,467,221             $   829,755
                   02                             19261,495                 868,408
                   03                             1,219,681                 908,043
                   04                               72  448

                          TOTAL                  $4,020,845              $2i6O6,206

             These ranges for the 02 and 03 year may be modified by action taken
             under conditions 3 and 4 above.


             @l@!LT     The findings of the site visit 14arcli 25-26, lq7l were
                        presented by the Chairman  of  the  team.  Major  concerns:
             1) organizational structure is cumbersome and the corporate Hong
             corporate delineation of RAG does not seem functional; 2) the roles
             of the Aims and Program Committees have overlapping responsibilities;
             1) CHP and RMP merging relationships seem awkward and may inhibit
             relationships with beal.th care providers; 4) core staff hidden
             objectives are not clear; 5) need for more clearl.y defined operating
             objectives and necessary data base;  6)  although  working  reasonably
             well, the review process seems unwieldy: and 7)   the  Coordinator  is






             NASSAU-SUFFOLK RMP              -2-                   RM 00066  5/71


             well qualified but because of his dual rol.e as director for both  CTIP
             and RMP, lie does need a full.-time strong administrative assistant  to
             provide continuous central direction to core staff.
             Some of the projects were apparently developed early  in  the  Region's
             planning phase. Projects were modified  by  staff  assistance,  rather
             than initiated by core.  Additional proposals are noi-i being,d@evelotied,
             and some of these may have a higher priority than those  -for  which
             support is oregently requested.

             As reported by the visitors, the Region's  accomplishments  to  date
             include assembling a staff and a fiscal basis4, conducting a number
             of studios as enumerated in the application; and the forniinL,, of
             cooperative arrangements. Some notable progress  wag  evident  in  that
             tile Region has been successful in: l@ getting the blocl,,  ohysiciens
             and dentists together to embark on medical. practice and pr  lem areas
             in the ghettos, 2) assisting the dentists in establishing a continuing
             education program; 3) assisting schools  in  establishing  community
               'hool health programs; 4) assisting industry and labor in exam'
             ac                                                                ining
             health insurance programs; 5) assistance in the design  of  I)re-pay
             group plan foundation; and 6) providing  technical  systems  assistance
             to induce cooperative sharing of comouter hardware and software.

             Some of Committee expressed disappointment i.n the  proposed  projects
             and their relationship to the stated priorities.  The Committee
             questioned the wisdom of RMPS funding research  type  activities  such
             as computerized electrocardiography and spironetry  (Project  #7)  and
             believed a Council policy statement might  be  appropriate.  There  was
             general agreement by Committee with the site visit findings an
             retommendati6ns.  The Committee believed the Region needed the
             challenge of operational status and recommended approval o  core
             as requested and projects at a reduced median  level  ($378,000)  as
             recommended by the site visit team.  The  Committee  also  recommended
             discouraging the Region from funding project nos. 7, 9 and 10.






                             DEFi.@TNIEtIT OF HEALTI-I
                                                               to

                                             PUBLIC HEAUI-H S-C--RVIC-E
                              HEAL'i'l-I SEFIVICR-S AND liENTAL i-IEAL@TH ADNRAINISTRATION


        Date.- 'i@lirch 30, 1971
         I,v fo
       Alin of.
       @Tubject.       eport o   the Ncissau-Suffolk Site Visit
                @)uick 1,      n
                March 25-26  1971 (Stony Brook, New York)
          TO.
                Director
                Regional @l@@cal Programs Service

                Through:  Actino Deputy Director
                          Regional Medical Pro-rams Service

                1.  SITE VISIT TEAM:

                                                                                  @IPS Staff

                    John E. Kralewski, Ph.D.(r,,,.'leirman)            Alan S. Kaplan, M.D.
                    Pli,IPS Review Committee                           Continuing Education Branch
                    Edward D. Coppola, M.D.                            Spencer Colburri
                    Consultant (Practicing Surgeon)                    Regional Developmental Branch
                    Paul E. Teschan, I,,I.Do                           Robert Shaw
                    Director                                           HEW Region I
                    Tennessee Mid-South Pdqp                           FIIPS Rep.

                    Chairman                                           Lawrence Witte
                                                                       Program Planning & Evaluat-ion

                                                                       Roger Miller
                                                                       Grants Management Branch

                                                                       Luther Says
                                                                       Grants Review Branch


                11.  STRUCTURE:
                The entire visit took place at-the Regionts headquarters ,71tli approximately
                60 area representatives.  Ilowever, the tTLeetiii- was structured along the
                lines previously augc,,,ested by the site visit team and the mission was
                                    ch three major sessions and seven sub-grou  discussions
                accomplished three.                                                  p
                attended by appropriate persons.

                First Session (3 liou
                                                                            Parti@alts
                1.  Organi@zat-l.op. and 1)(-cision-@                   Site visit Team (9)
                    Makin6 Structure
                  - Legal Structure                                    -Offit6rs (4)

                  - Governin@_ Bodies                                  -Attorney








                                                  -2-

                                                                     IUG Corporate members (4)
                -   Regiooial Advisory Group                         (3 consumers & 1 provider)

                                                                     RAC non-corporate members (4)
                - Chief@Operating Officers
                                                                     (3 providers & 1 consumer)
                - Goals, operating objectives                        Chairmen (2)
                                                                     Aims & Program Committees
                  and Priorities
                - Activities Underl,7ay                              Coordinator &,Key Staff- (3)@

                - CHP & PDIP relationships

                - Manaoement Inforn,6tion System

                - Accom li8hraeftts
                         p

              Second Session   (4 hours)
              2.     Operational Programs                         -  Site Visit Team
                     Development                                  -  Officers (4)-
                - R6view procedure                                -  Chairmen (2)
                                                                     Aims & Program Committees

                                                                  -  Key core staff
                -  Role  of  RAG
                -@Staff assignments                               -  Project authors (10)
                - Priority assignment                             -  Medital Societies
                                                                     representatives (4)
                - Evaluation                                      -  Hospital rbspresentative..3 (4)

                                                                  -  Dental Society (2)
                - Plans for phasing but
                  RMPS support
                                                                  -  Health  Department (2)
                - Regionalizat on
                - Cooperative Arrangements                        -  University (2)

                                                                     CHP representatives

              3.  Community involvement

                                             Discussion Groups (4)

                                             1.   Project   Authors








                                              -3-

                                       2.  Health Institution Representative

                                       3.  Planning Agency Representation

                                       4.  Community Representation


             Third Session     ours

             4.  Staff Or-anization                           -  Site-Team
                 and Activities
               - Line and staff organization                  -  All professional core
                                                                 staff (9)
               - Task allocation


               - Personnel & turnover


               - Internal operation
                 activities & accomplish ments

               - Ilaftagement controls
                 including data base, monitoring
                 and evaluation


                 Budget review

                                       Discussion Groups

                                       1   Budget revie-vi

                                       2.  Staff organization & management

                                       3.  Continuing I'ducation

                                       4.  Acconiplisliv,-ientr,


             Fe6d Back Session

                 Observationp & Recommendations              -  Site Team
                 of Team (no mention of recommended
                 funds)                                      - Chairman of RAG

                                                             - Key Core (9)

             Ill.  SU@IMARY OF FINDINGS-.

             The multi-faceted organization Near inherited.  The RAG membership remains
             relatively unchanged since 1969 and a rather load level of attendance
             of meetings w6s noted.  The corporate and non"corporate membership
             appears to have created a cumbersome situation.  The question arose as to
                              .1.                     AG (corporate and non-corporate
             the functional differences betx.7een the It








                                                 -4-

            members), t@e Board  of  Directors  (corporate  members)  and  the  Executive
            Committee.

            'Th6 roles and interchanging relationships of the Aims and Program
            Committees are not clear and there is some question about their
            sense of direction.  The project review process was considered cumbersome
            bu  is -working  odetate'Lv @?elli
              t

            Of major concern to the visitors, was the i-,ir@rging.functions  of  CHP  and
            MP  i.e.  integration of the two staffs  one staff dirc@cto-t-@for both
            agencies and the  mergina of the two Aims Committees.  A more
                                     C,                                      -formal
            merger  is under  consideration which is to include the Lotic, Island Health
            and Hospital Planning  Council.  The  visitors  believe  that  this  meld  has
            contributed to the  Rbgion's  waning  influence  with  the  medical  community.
            Two separate  and  distinct  agencies  with  interfacing  relationships  might
            be more effective.

            The Region's priorities are reasonable and  relevant  but  there  is  ,a  need
            for more clearly defined operational objectives and necessary data
            base. Core staff aversion to  acquisition  and  use  6'L  data  was  apparent.
            @Operational Planning see,-,is to be more by the  "human"  approach  rather
            t  an  the  "quantitativ6"  approach.  "Hidden  objectives  exist  but  are
            values

            .16t6rnal affairs are on-a sound footing, particularly since the., "Managor6ent
            Assessment Visit" conducted in July 1970  by  PD,IPS.  The  Region  is  doing
            a good job in personnel management.  Fiscal services, including purchasing
            and prdtiipt reporting, are adequate and the costs are very reasonable (10%).
            There was st@@.,Iqe concern, However about the many  responsibilities  of  the
            oordinator and the  need  for  providing  central  direction  to  the  staff.
              full-ti@vie strong administrative assistant (deputy) is needed.

            Some of the projects  were  apparently  developed  early  in  the  ReQion's
                                                                               C,
            planning  phase,  Projects  were  modified-by  staff  assistance  rather   than
                                                                          . I
            initiated:by core.  Additional proposals are now being developed., and
            some of these may have a higher priority than those for which support
            is presently'requested.

            The ReRion's accomplishments to date, include                 a. staff and  a
            fiscal basis; conducting a number of studies as enumerated in the
                                    C>
            application;  and  the  forming  of  cooperative  arrangements.  Some  notable
            pro2res  %,.,as evident in that -lie Region has been successful in: 1)  ettina
               11                                                                     9
            the black physicians and dentists together  to  euibark  on  medical.  practice
            and,problem areas in the ghettos; 2) assisting the dentists in bstablishit-i("
            a continuing education program; 3) assisting schools in establishing comnu6it
                                                                                                y
            school health programs;  4)  assisting  industry  and  labor  in  examining
            health insurance programs; 5)  assistance  in  the  design  of  pte-pay  group
            @ien ioundatloft, and 6) providing technical sy8tecits is,,3istance  to  induce
            cooperative sliarin@ of computer hardware and software.








                                                   -5-


             IVi  RECO@Pi,@'ENDATIOliS:

           @ApproVel for operational status for three years with the following
             conditions:  1) that the Region obtain the services of an outside
             consultants to assess the current organizational structure including
             CHP-@IP  relationships;  9)  that  the  concerns  of  the  site  visitors  be
             communicated  to  the  Region;  3)  that  the  second  year  continuation   appli-
             cation be reviewed by Committee and Council in addition to staff and
             4) that the level of funding be increased if significant pi-ogress has
             been achieved during the previous year.

             The site visitors recommended approval of th      e  amount  requested  for   core
             activitiesias    follows:

                           01                         02

                        $451,755                  $490,1,,OS             $530,043
             The first-year request for eleven operational projects is $1,01.5,466.
             u    rt is recociii
             F, ppo            a nded at a reduced level in three ranges as follows.

                                     Maximum                   $423,000
                                     liedium                    378,000
                                     Minimum                    326,000

             The tot8l. amount  recommended  for  tne  01  year  at  the  maximum,  medium  and
             minimum amounts are:

                                       MAXIM@I              111'@DILT@4         IIINIMIIN

                  Core                 $451,755              $451,755             $451,755
                  Projects              423 000               378.000            326   OQO
                       Total           $874,755              $899,755             $777,755
             These ranges for the 02 & 03 year may be        modified 'oy  action  taken  under
             conditions 3 and 4 above.



             Lu         Says ,
             Public Health Advisor
             Giants Revi-ew Branch'





                                                                        11 11 11 @ @
                                                                        I,.,J. Says



                                        Sl'f'v- VISIT REPORT
                            NASSAU-SCFFOI,K REGIO'@INIAL MEDICAL PROGRAM


                                        March 25-26, 1-971



                 SITE TEAM 1,@l- IBERS

                 John E. Kr,-il@@isl@i, Ph.D., Cl-iairriin, Review Committee Member, Chairman
                 Health Administration, University of Colorado, School of Medicine,
                 Denver, Colorado


                 Consultants

                 Edward D. Coppola, I.I.D., (Practicing Surgeon) Associate Professor in
                 Surgery, Ilahne-,nann Medical College, Philadelphia, Pennsylvania

                 Paul E. Tesclian, M.D., Coordinator Tennessee @lid-South Regional
                 Medical Program, Nashville, Tenn.


                 P,@,IPS Staff


                 Alan S. Kaplan, M.D., Continuing Education Branch
                 Spencer Co]-burn, Regional Development Branch
                 Lawrence @,.7itte, Office of Planning and Evaluation
                 Robert Shbw, HE14, Region II, New York City
                 Roger Miller, Grants Management Branch
                 Luther J. Says, Grants Review Branch

                 REGIONAL REPRESENTATIVES


                 Officers of @@ISPDNIP


                 Edmund D. Pellegrino, M.Di, President
                 Reverend Richard P. Hendel, Vice-President
                 Frank Gibson, Secretary
                 Henry Bang, Treasurer

                 Members of the Regional Advisory Group

                 Costas Lambrew, M.D., Chairman    Al.,ms Committee
                 Edwin Clare, Attorney for IOIP
                 Leonard An-dors, D.D.S.
                 Ms. Priscilla Roe
                 Leon Rushmore
                 Lawrence Scherr, M.D.
                 William Warner





                                                            2
                  Nassati-Suffoll@ ILTIP


                  Project Authors

                  Martha Browning, Comprehensive Home Care
                  I.indoLi Davis, iI.D., Stroke Peferral'& Evaluation
                  I,lm. Messinger, '@I.D., Regional Approicli to Co-,nptiterized EKG
                  Paul Diamond, l'i.D., Regional Approach to Computerized EKG
                  Walter O'Connor, @I.D., Development of PAP Smear & Self Breast Exam
                  Ms. Stacey Sal.ev,-Regional Medical Library
                  Ms. Elsie 1,@Tilensky, Regional Medical Library
                  Perry Mandel, ',I.D., Computerized Ridiation TI@)erapy
                  Harold Aqtorita, Computerized Radiation Therapy
                  Sister Marie Buckley, Si-noker's Withdrawal
                  Ms. David Arella, Smoker's Withdra\qal
                  Daniel DePonte, Curriculum Development
                  Sisiter Jane Marie Durgin, Regional Drug Inform3tioft
                  Clenna McLean, R.N., Clinical Nurse Specialist
                  Emil- Frey, Pli.D., Dial Access Lecture

                  Health Institution Representatives

                  John Dowling, l@.D,, Nassau County Health Dept.
                  Micheal Bustemi, M.D., Suffolk County Health Dept.
                  Leo Fishel, I.I.D., Nassau County Medical Society
                  Maurice Tulin, M.D., Nassau County Medical Society
                  Milton Rosenberg, @',.D., Suffolk Couity Medical Socioty
                  Walter O'Connor, M.D., Suffolk Countyi%ledical Society
                  Jack Dillman, Executive Director, NassAu-Suffolk Hospital Council
                  Martin Nester, Administrator, Long Beach Memorial Hospital
                  Francis Fosmire, Administrator, Brookhaven Memorial Hospital
                  Richard Schoen, D.D.S., 10th Distri.c Dental Society
                  Robert  Brunner,  State   University  Health Sciences Center

                  Planning Agency Re2resentatives
                  Henry Bang, Exec. Vice-President, Long Island Health & Hospital
                  Planning Council
                  Reverend Richard Hendel, Long Island I-Lealth & Hospital Planning     Council
                  William Warner, Chairman, Comprehensive Health Planning Council
                  Ms. Louise Pan, R.N., Comprehensive Health Planning Council
                  Ms. Joyce Turner, Comprehensive Health Planning Council
                  Sanford Lenz, Comprehensive Health Planning Council

                  Community   Agency   Representatives

                  Arthur Risbrook, M.D., Clinical Society
                  Sister Marcella Ann Hannon, Home Care Task Force
                  Joyce  Turner,  Brentwood   Schools*
                  Mark Kenyon, Medical Foundation
                  Eugene McNamara, Business/Industry
                  Sanford Kravitz, Health  I,,Ianpower
                  John F. O'Donnell, BioMetric Systems
                  ,Wm. Larregui, Suffolk County Task Force
                  James Culhane-, Suffolk County Task Force
                  Louise Pan, R.Ni, Task Force on Nursing Education
                 ic@is. Pan and Ms. Turner represented their interests at both groups.





                 I,I,ac,sau-Suf folk                   3


                 Core Staff'

                 Glen E. Hnstings, II.D. , J-,xecutivc, Director, P !I' & CliP
                 John Kress, Assistant Director for Technical- Support
                 Steven Roth, S37St&,-@I.S Specialist
                 Sharon lianiil.ton, R.N., Planning ',,s,-,oci.atc-, Project Grants/@lanagement &
                 Development
                 James R. Europe, Assistant Director, CIIP
                 Harrison OweLi, Assistant Director for Organi.zational Liaison and
                 Special Projects
                 Robert Beckman, Coordinator for Evaluation and Planning
                 Annette Gilpin, Administrative Associate
                 T4illie Paye, Planning Associate







              liassau-Suffoll@ I-'_,,Ip           - 4

              PUR'4DOSE: In li-lit of the present initial triennial application for

                         operational status, the site. visit       conducted  to  study  and
              assess the Region's pToor@tm structure, achievements and capability.


              SIT'@, VISIT ST,@t,'CT IT

              Prior to the visit, I'-',TS documents       Revie@.7 Process Requirements and
              Standards" and "I-'roram Revieiq Criter5.,@, were provided to the Rc@gion  and

              the site visitors.   'ITe lallter was used as i clicc',-, list in structuring

              the agenda and in the conduct of the visit.


              T'ne entire meeting too]-, place at the           I,,caclquarters @,.,,i.th approximate
                                                        C,                                      y
              60 area representatives.    Illo-vl;ever, the           -triicture,,l along the
              lines prc-v,o-,iE'!,,        I)v the --tc vif"it tcel  -,Lid the i@-tis,.@ion was

                                     three major sessions at-id       smaller subgroup

              discussions, each attended   by appropriate persons.


              Tiie first session-(3 hours) with their otficc-,,rs, -onie f@,G members, the

              attorney and Key sta@@-f, f--cused on               structure; -oal@--
              objectives,      ,-riori-ties, achievements,              information, and
              Cl-',P-I7@@.P relationships.  The second session (4 hours) also included project
              authors, providers, consumers and other health interests groupsand
              centered on operational programs (development, reiiew, evaluation and
              phase out plans), and regiorializatioll and cooperative arrangements.  Tiie
              discussions were further amplified through L'our small groups;.l) project

              authors,  2)  health  institutions  (Health  Departments,  Medical  Scoieties,
              Dental Society, Hospitals and University),'3) planning ai,cncies, and

              4) local or gani?.ations.








             Nassati-Suffolk

             The third session (3 hours) on the second day was with the principal, staff

             and dealt with staff organization, task allocation,  personnel,  internal

             operations, management controls and budgets.  Small discussion groups
             included 1.) budget review, 2) staff organization and management, 3) continuing

             education, and 4) acco,-iiplisli,.rerits.


             The meeting concluded i..7ith.a one hour feed back of observations and
             recommendations (no mention of 'Lunds') to the Chairman of RAG and principal

             staff.


             S[Il@ri.,,!Ar,Y OF FIi\TDI@'CS: Until South Dekota's recent separation from Nebraska

                                   Nassau-Suffolk was tli,L- last of the 55 Regiotis still

             in planning.  After two and one half years in planning, the NSI:VLIP is now
             requesting operational status and initial support for core activities and
             eleven projects. Core funds ate requested for  three  years,  one'project

             for four years, eight.for three years and two for two years.


             I. Historical DevelopRient
             The Region encompasses Nassau and Suffolk Counties comprising  100  miles
             of Long Island east of Queens. The area was originally  included  in  the
                                                             C,

             Metropolitan New York  Regional Medical Program. The efforts to  be-,in  a
             separate region began with  the formation of a Advisory Medical  Group  in
             1967.  In June 1968, the  Group incorporated as the Nassau-Suffolk
             Regional Medical Program,  Inc. operating within $10,000 contributed by
             eight interested agencies.  More than eighty organizations supported the
             new region in its planning. The Metropolitan New York,  Regional  Medical
             Program agreed with the two counties that it was reasonable that Nassau-







            Suffolk Counties form a separate re(,ion         cc)gr@iplii.c@ capability with
            other riiajor relat:L-,@c@ orf,anizztio,.-Is, c@.@,. ti@(@ Lon- lsliricl Tlospital and
            Health Planning CoLipcil; the State        I)c@.,p@irLi@ient for CIIP; the l@,assati.-
            Suffolk Regiocial.Planning Board, financed by PUD for planning in housing,

            economics and educational development; iiid the New York State Department
            'of Mental Ilygiene.  Distance and tran Spott&t4. on posed  difficulties  in
            developing vital relationships bet@veen the counties' health professions and
            ttie ,@,ietropolitan I-I.Y. medical centers. The rie@,..7 Ilealtl). Sciences Center being,
            develop' d at the Stony Broo,@ Campus of SUIZY is bririF4-Ln@ [tracheal center
                   e

            competence directly to the 14-Sl@,,P.


            !'he developing Stony Brook 1--iealti-i Sciences Center is to include Colleges
            of Medicine, Dentistry, Nursing and Allied health; @i School  of  Social
            Work,, a Health Sciences Library; a University Hospital; @i@qd a VA hospital.
            Other resources in the region include 41 hospitals, county health departments,
            several specialized research facilities, and the Brookhaven National

            Laboratory.


            Support was approved L@or two years of planning beginning January 1, 1969
            (bl-$223,256 and 02-$320,024.).  There Xmas little activity until the
            appointment of the Program Coordinator June 1, 1969 and subsequent staffing.
            For this reason the planning period was extended for  six  months  until
            June 30, 1971 with no additional funds.  In lieu of indirect costs, awards for
            ,direct costs including fiscal.agent fees, $29,755 for the  first  grant
            period and $30,245 the second period.  The fiscal agent is Stony Brook

            Foundation.







              LN'assau-Suffol,',( TRIP            - 7
              Of particular interest has been the Lesions li@@k-itP  i.,,i.th CIIP "b" and the
              Lon- Island 11(@,alth ii-Icl Hospital Pl@ni-,i-ng Council.. The Program Coordinator

              heads both @IP and CIT.P, and offices are share(] by L)otli groups. A more
              formal merger of the two  agencies  is  under  consideration.  The  Health

              and Ilospit.@l PI-arin4pg Council is also considering joining t e s aring,

              ol.- quarters.


              @l. Goals, O'i)jectives & Prior-',-,U-ies

              Operational planning seems to be more by the "human" rather than the
              quantitative approach. '-ihe goals, objectives, and priorities have
              evolved from a "laundry list" of perceived problems.     l@iiile the priorities
              set by the organization seem to be consistent @@ith the needs of the
              country/in general there has been little effort devoted towards the
              collection of data to determine specific  needs  and  priorities  for  the

              Nassau-Suffollc region. As a result the  @6neral  priority  list  has  not
              been developed into operational objectives other than for the staff to
              go forth and do good under the general direction of "hidden objectives".
              The staff believes they can not  promulgate  these  hidden  objectives  in
              writing because they would create too much an:<iety among the health
              care producers.  The "hidden objectives were not clearly understood to
              the visitors, nor are they understood by all the core staff.  There is
              need for more clearly defined operating objectives and necessary data base.


              @ll. Organization Structure

              The Regional Advisory Group is made of 82 members with heavy representation
              from the medical community.  The attendance of meetings has been about 40%,

              but it appears that those  attending  represent  diverse  interest  groups








                             consu@,-,@.,,r anci producer         in                   eqLtil     numbers.

                Tii,- Re@,ioiial i'@@v,'-sory GrouD is             of              and    iioi-i-corporate

                i @i e @,,-i b r@, r sin        a three to one rL-@'@ic)n il,,.tli the c(.)Y.,porete members

                Ic@3a]@ly responsible for          agei-icy      the entire (@rotil) acting to advise

                the program in terrqs of -o@il.s and                        a'i'ic@ del4Election   of   these

                responsibilities is not clear to R-@G ii-,c-ml)ers -,nci i-,iost do not krioNq

                whether they are corporate or noft-corporate                        The  ILAG  i.nitiall,,,

                was the incorporati.r.- body but was expanded aii(i split           into   -,    corporate

                noti-corporate configuration when the propriety of the              sin,@lle board concept

                was questioned by F@',IPS.     -,'@-Ton-corpora,Lc-,, ,ierribr--rs lia-\,e all ri,,,Xlitp, except that

                of holding office, however., they may be eR observer on a c-,)iii,'RittLe'if

                appointed by @he president.          Both corporate and iioi,i-cbrporat(@'. raeiil)ers

                are elect8d to three-year terms without pay.   Their function is to approve

                all contracts and applications for rrants at tile (-,uarterly riceti.ngs.   Two

                standing   committees   assist   the   l@G:   1)   the   Dominating    Committee    and

                2) the Aims Co7i7,ittee.      The                Cciiir,.ittce,   seven   members   elected

                by  the  P,/iG,  nominates  replacements  to   the   RAG   and   its   own   committee.

                Noniinations  may  also  be   made   in   writing   by   any   five   corporate   members.

                The  Ains  Committee,  composed  of  10-30   voluntary   r.,ieriibers   of   the   Advisory

                Group,   considers   available   data   concerning    liealth'iieeds,    and    assists

                the  P@G  in  its   development   of   short-range   and   lonc,-ran,,e   proc@ram   goals

                and  m@al(es  recoT,,Tiendations  to  the  Group.   The   officers   are   Presi   ent,

                Vice-President, Secretary and Treasurer and are elected by the l@G.

                The  same  officers  head  the   Corporation,   the   rAG,   J.Ioard   of   Directors   and

                E),Ipcutive Ccm.-,iittee.






              1,4assau-Suffol',@ IC"ll)          - 9

              The Board of Directors consists of 30 riciiib,-rs rel)r(@set-itin,@,
              health providers, health interest          and              The  Board  meets
              monthly and carries cut the corporation  is business during the interim
              bell-x,iec-Li quarterly ff,,eeti-,i@s of the l@G to wiii.,cli it reports. The Board
              e@ipl.oys the ll;,(2cutive Di-rector as its chief' adi-tiinistritor to carry Out
              its policies and programs on a day to day basis.  'I'h-C  Executive  Director
              lips i-e,-poisil-,ility to ?,ire, fire, train, direct and supervise staff
              m ciii.rp-rs, x,.,Iio are authorized by the Board. In      the Executive
              Committee, composed of the 'Lour Loarcl officers      chairriif@-ii of the three
              standiri- committees of the Board (chair,-,icii are elected from the Board by
              the Board), conducts the affairs of the corporation in the interim beti-yeen
              monthly Board meetinE3, at which tinie their  actions  are  ratified  by  the
              Board. On the advisory branch  are  the  three  standing  committees:  1)  the
              Administrative Committee, which is in charge  of  the  budget  and  financial
              policies, and forms job descriptions; 2) the Pro-rapi and Eva uation
              Comliittee, which coordinates and reviex:s the pro,,Ira,-,i activities, and reviews
              all projects for possible funding; and 3) the I.'.rtTibership CoTtiriiittee, which
              recruits members and determines classification of members for recommendation

              to the Board.  llenibersliip on these committees anri subcommittees  are  not
              restricted to members oi the Re(,ion.al Advisory Group,  and  are  chosen  by

              the chairman with approval from the Board.


              IV. Internal Affairs
              The Executive Director of N-S @IP is also the director oi the CHP areawide
              "b" agency.  CliP and L14P activities, are tl-icrefore closely interrelated
              with both sets of activities carried out by  a  16-man  staff  (ten  paid  by








                                                           10

                               funde-, @)y cllp.  '@ic  roles  of  t'c,,(@  various  staff  Members  are
                luip and

                not 1.@ell defined   and there a,-)pear-, to 1,@io some a,-iL-,2,-@uity as to  who  does

                wha t.  This                 is fui-(-I-,er cc)i-riplicated by the fact that fully
                half of this staff report                  to ti-- l@',@:ecLitive Director whose dual

                Ci.IP-ll,@.IP  role  leaves  him  insufficient  time  for   internal   -dininistratiorl.
                'Elie visitors believe a full            strc-,,,i,, Adr..-14nistr@itive Assistant (dc@puty)

                is needed.    Other tl)an the need for provi..,,Iiti-             central direction to
                s@a'Lf,  internal  affairs  are  on  a  sound   j@ootin.,   particularly   qi.rice   the
                "liar)a-er-,iont Assc-ssmen@, Visit" by rdiPS ii T,,-ily, 1970.    Fiscal      services,

                including purchasing and prompt reporting, are adequate and the costs

                are very reasonable (10%).



                V. Pro
                Some of the projects were apparently developed early in. the Re-ion's
                planning phase.   Pr64ects were modified by staff assistance, rather then
                initiated by core.  Additional proposals are now beint@ developed and
                some of tciese may have a higher priority than those for which support is
                presently requested.   Some of the newer projects considered', definitely
                seemed consonant with Regional Medical Procram goals and offer the

                possibility of chanaing health care delivery in 6 significant wayi
                However, these projects and ideas came along after the present operational
                application was sub,n4.tted to RI@IPS and many of them have been incorporated

                into the new Comprehensive Health Plannibr, application.


                Vlhen the Core Staff was asl@,ed how they could prevent themselves from

                bein,, boxed in once the present projects in the r'-!,IP application had been

                started, the answer was that they will continue its local action








                              ip

             ,iticl orc@-anizin- a ctiv-i-ties .ri a, c,)iis-,Iii tive fOpti-i-@ii, s t-
                                                                               A.C SISILIS

             that this        I)e an ef@L'ccll-i.vc- assay to r,o are tliit at least four or five

             medical community groups        come to t@'ticin     for advicc@  of  various

             kii:,tds. In. order to ii,@iidle flat apl,)e@,rs to IDC, In increasing .Imount of

             advisory and consultative ac@tivi-ty,      Staff ,%7()uld subcontract for
             additional needs as they ar,.se inste@id ot            its own number of
             personnel.   T@ie main way in which the           PJvisory Group would appear
             to play a role 't@crc is throti@.,Itl'the Proe@'raTii   and the limits Committee.

             The Core Staff feels that- the potential for lea6erct@iip in these committees

             is fairly good.


             The i!-iajor accom-f)lisl-ircc,-nlk@@.s of the pro,lr.-@.n to eiate tilve been:I  setting
             up a '@ore Staff which se&-,is to be sensitive to co@.ii@-@iinity group dynamics-
             2)          closely with the activ-@st -,,.Retailers of the I)ro,,raiii and Aims
             Committee of the Regional Pdvisory Gro-al); 3) community   or&,anizi.n,,; and
             4) responding quickly-and enthusiastically to requests     from the professional
             medical community for guidance and assistance in approaching problems of

             health care delivery.


             Examples of such accomplishments are:
             1) Or@.anization of the 1--lassau-Su@lfo-Lir Clinical Society.  This is an
             association of more then 80 black doctors and dentists which is addressing

             itself to,healtl, care needs  of  the  minority  population.  Sixteen  Health
             Committees of this group have-been  formed,  which  have  both  consumer  and
             provider representation. They  are  interested  in  working  on  sickle  cell
             disease and other problems peculiar'to blacks.     @lo  project  applications
             have yet come from this group but it is- anticipated that they will.








                                                      12 -

              2' School                                      Stif@'i is         with school

              districts since they are             by                 aid pro-vi e Li  means
              to get at a defiiiecl population.    They are interested   in  the   relationship
              of poor health to ,,i,-,,cier-ach-',-evc-ment in scl:ic)ol and hive  the   health

                                             strict officials to sit dc)-@@;n to@,
              department and the schoo' di,                                     ,etlier  and
              look at  these  problems.  Health  aides  r@urse2s,  and  doctors  are  -radually

              being involved.


              3) Labor a--id                            The premise here is that the way in
              @,;hich health care delivery can be influenced requires participation of

              influential community aroups.  The Core Staff has talked with representatives
              of labor and industry and pointed out -that they  were  spendin(,-  $'>'47.  per
              year on employee health and the c,-,,ployees @@.-,ere          igL@in at least
              that much. It  was  pointed  out  that  pre-paid  care  could  probably  do  the

              job cheaper and better.  Various public utilities and private corporations
              are involved in tl@cse  discussions.  An  informal,  @,roup  has  been  organized

              which has 'oeen meeting for a year and in tli(,@  pas,t  year  the  membership
              of  the  aroup  has  doubled.  These  companies  are  currently  spending  @40
              million  per  year  an  health.  Insurance  companies  have  been   approached
              and representatives from  them  have  joined  the  group.  PAIP  Core  Staff  is
              ,assisting this group  in  plannin-.  The  response  from  the  medical  coiimun 4ty
              has been either "rion-plu-@-"ed" or very interested.  The Fassau Yedical
              Society has-r.-)ade iticuiries about being a potential bidder for such a

              health plan.


              4) There are five other potential groups starting to look in this direction

              and they have come to r@iP Core Staff for advice and assistance.









             N2@ s s,.

                  program for pro,.@idin,, health c@,,re to the poor-liacl been planned

             with the Riveric-,,ad          Tiie D@@,-,@rtiieit of    I:)a(l coz:,,tfiittcd
             @,'300,000 to     proi(,Ct owns   was           to c--iiit-,iit $100,000. Vi e
             hospital had a,,-rccd to -fc)rir4 a Depa.@teitnt of     l@lerJici.ne and

             ha.f-i approval of the hospital adrcii@rii@-tr@t:or and board of trustees.

                       the pro-rani x,,as defeated by one vote in i medical staff iu(-,eting,

             preventing its initiation.


             6) P. similar type ol' pro<,ram is bein- developed at the Brookhaven hospital
             although some details of '-the              are not quite the same as the

             P,,!.vcrhead Ilospital project.


             7) Core staff are workinc, Keith the evaluation coiyil,)onent of the
                                      C3

             Southwest Suffolk health Proc-ram which is a joint CEO-IIIP  program  from

             2500 i.@elfare recipients.


             8) Assistance is being given to the O"uffoll< County Ilealtli Departnent in

             preparin- seminars for county legislators.


             9) Staff is also assisting the dentists i[i establishing a continuing

             education program.


            10) Technical systems assistance is provided to induce cooperative sharing

             computer hardware and software.


             VI. EVALU@iTIO@@': The Region has developed a critical pathways  form  for
                               project monitoring. T,'ne concept v)as developed by  the
                                                 C,
             construction industry several years ego (also called PERT) and allows for monthl,








                     -Li - "-u f


                                                                                              s m ay


               Lc@ co,;,parLd to



               l@IC)St ol tllr
                                                                             1)@TL the lic@ioii's  overall

                                       is va,-Lc,                               of data l@ase.     The

                      11-IC-s studi(@d the evall,,@tioli               O.' other rc.,@,,iois, as well

               as               o',--her reunion,,; coq,,-icnts on its    approach.     Outside

               consultation is bei-,.i- sou-iit as evidenced by the                  participation      in
               t@e multi-r6gional program       c-,7a lua t@LoLi throur,h tiip lizirvnrd Cc@,nter.


               Phase I of the H@irv,2rd study includes ,ti                    ,3tue;.y of  17  staff

                                                by                                -ion
               (10 paid by 'U@-!P and 7 paic        CIIP), 27 P14."@(,l      (1.0 i  -corporate     and
               17 corporate), and 25 non-P,@,.G merni)(@rs.     T'LIL, 1,@,tLcr 52 represented some
               of the most"influential people"                     those in health care.       Preliminary
               results indicate the Region's first order of priorities are congruent with
               major  health   problems   identified   by   the   respondents.   The   second   order   of
               priorities  should   be   reevaluated.   -L'ne   projects   for   which   funds   are
               requested address a large number of the                     major    health    problems.
               All  respondents  agreed  that  the  major  pur@,,Ds,-s  of  @qSI@'IP  should  be  to  plan
               and   improve   health   care   in   general.   The   greatest   current   visibility

               of NSR@IP seems to have been       generated  by  activities   unrelated   to   llbip

               projects per se.   This phenomenon is to be                         after   the   Region
               is   funded   and   operational.   All   respondents   predict   a   merger   between

               @IP  and  CHP  at  local  and  national  levels   and   are   otherwise   uncertain   of


               the future of 1-1@IP,










                            11  c



                                      I c@ 0,

                                                  i-I c  p                                                -'le  Ic)o  y
                                                                                           @',)'!,y had   to


                                                                                           -iie riiaii)y in  --s
                  structured durin- tl)c- format@j-,,7e ye,-,rs       ',@O  OCCOPI!,,Or@"LIL@-I          tei.   t

                                                                                                       c@
                                                                                           of   1; c f@e@
                   roLip s     t i-,,r:) V 4  the              for             IC)!),-        t -      -i,bnal

                                                                                                       s c@ c -,'k. a I 1 y


                                             not
                                                    -vc- a                       to   r;rc@%,


                  role
                  believed that the -.tiality        oi the top                     i,); the corpoi,--,tion: w--)c@  oF
                    nature that ..4-OUld iris-tire                    success of tiie program.          Therefore,
                          the team shared many reservations                                        organizational,

                  structure @r,,df state of the corporation E,,iil pro-r@j@L C,,C--'--,7C-lop.Tnent , tLie
                  N,T,- s --Ltots @,eli@-ve that the           has o-          deal of potential and fill

                  benefit from and congequen-LI.y do justice to the challenge of  an

                  operational proc-raf@i.


                  L4ajor Crincerns:
                  1) Tiie corporate structure is cumbersor@-,e and the corporate non-corporate
                  delineation among the Re-ional P@dvisory Group iDe-c@iberstaip is artificial and
                  disfunctional, therefore  this area should be re-exar@ii-ned and possibly

                  restructured.
                '2) The role ot the Aii-,s and Objectives Committee. versus that of the Pro-ram
                  Committee is not well defined and as a result it appears that these L@,C,70
                  groups have overlapping responsibilities for the development ot l.onc.--range
                  plans.  A more worl-,able        arrangement should be developed for  tiie
                  determination of lori-- and short-range goals and the structuring of
     0            programs to meet those goals.                                             I






             3)  Toe internal or@,,a;-.-zation oi:  L@,@c o;-,            -ind dirc-cti-o@l,
             Its 2       it appco,@-S  that -Lit,c@                      on @i  reactive

             rather then  free-float-"-nE,, basis @,,,-'@th no cic,,,3r cut
             4)  -ilic.                     rysi--c:ii V,,,-'@thin  the oleratin,-,  level of the
             orgeni;.,,ati-c)i-i @pl)Ie,,,-rs to be relat4,lvelv I,"iost@  of  the employees
             report their progress  to  the director or, an informal  basis    few
             opci-atiii,,  I.ittlc, :rLc@asureiieit to       they are qctuilly achieving
             results.  The methods by wliich t,ie director reports  to  ti-t-- bo@ird  seems  to
             be more structured alt',-iou--h ,,,,.uch of it is 1) sod on   communications.
             5)  The salary  structure and allocation of resources  in the or,@eni,--,,,,tion
             appears  to have been accomplished on a rather liapli,3z,-3rd basis.   Some  salaries
             seem hi,,h  for tne l@inds of talent being hired.   It also ippear-,  thit the
             various  talents have not been !)rou'@,,',..t  tc),-IeL'Lier to  'JI-or@@ll @l  composite group
             who would accommodate and build on each otiiar's e:@pertise.  Same other
             Core 'D-adc,et items see,@ equally itap--rudeiiL,            costs (plan
             to relocate in th6 near future) and consLiltiiA- services for writing ,@tant
             applications.  The internal administration of the pro,@l-r@@m should be
             thoroughly reviewed and strengthened.  Consideration should be given to
             employ an administrator to provide continuous day to day direction.  This
             is especially important since the coordinator heads both CIIP and PIIP activities.
             6) T'iie project review procedure is extremely cumbersome with the &@G being
             I-,rought into the picture much too late in the process.  l,,cviei,2 procedures
             need to be streamlined.  It was noted that the review procedure appears
             to have incorporated proper scientific and managerial reviews to insure
             integrity oj' each project a]-though it is.di.L'ficult to see how the projects







              a S    -Uff(-                        )@7
                  L@ LI - S,


              fit into a total,. proZram.
              7) Too little ef,7ort: his been             rc.1           -i."ojocts     more
                                                         -i

              realistically meet      i?,Oals of                    As a result t:li4-- program
                                                      C'
              is riade up of project- developed on ,i rr@ore or            basis with little-

              pro-r@@..!)l consistency.
              8) There is concern ibout the close relationship            the Pl@,P and CllilP
              and the evident- corifijsion't,@@is  (,_@-usc@,d i,i,-i Lljie viii.iicj's of the health
              care practitioners.   Some of the site-vi,,it tc@@-,r@i     T,.,,ere concerned
              that the region has lost at i-easL same of the supi)o,-t oj' the  medical

                  Un4ty4  They believed that in part this is
              c 0 nllrriI                                      due to t'ie close

              relationship with CIIJ'-.
              9) There has been little efi@ort t-j,,,@,a-cds         irid use of data to
              determine specific needs and priorities.    As a result the -,zcncral priority
              list has not been developed into ol)r@retiorial objectives   Also   there

              are too many hidden object:L@70S.
             10) Levels of attendance is relatively low at tlif-- Air,,is )iid Program Comriiittee
              meetings when the  priorities  were  being  established.  Those  present,
              however, did represent a -ood cross section ot consumer ai-td provider groups.

              RII,CO,Nr,!Ft-,ITDATIOI,.T: The site visitors recommend t@Liat the Region be allowed
                                to go operational ind believe that by doing so under
              Specific guidance and advice frofa fl@iPS, the pro(,ram will be greatly
              strejagthencd.  Therefore, approval is recot@iricnde(i for three years,-with
              the following considerations: 1) the P@@i.bn obtain the services of

              an outside consultants to e@-at-@iiiie and assess the organization structure








              N"gssiu-Stiffoll,


              c,iicl                     vl-litl,,                            tmq,-,rd the


                                       2)      fc.@,ion ddrcs,@:11 the concerns of the

              visitors; 3) the second year                  ap-.)Ii-c@ition I)C-, reviewed by

              Comi-nittr--c, and Cotinc-.'Ll and   c.@ site        ariej 4) that the level of

              funding be increased if sifrificilit pro@ress is achieved dilrilic, the first

              operational year.


              ror core activities, trie site vif-,itors reco7,iiL,,Pl @-pproval of the amounts

              requested as

                        01                        02                       03

                      $451,755                  @490,403                $530,01@,3

              For eleven projects, @1,015,466 is requested          first year, $771,087

              the second year, $6,@)9,6-JOU the th-@@rd year anci @72,4,!i8 the fourth.A

              reduced amount is recorrinended each year for three years tit one of three

              levels as folloiqs:




                        $423,000                 $378@000               $326,000

              Therefore., the total for core and projects is recommended at one of

              three levels as follows:


                             01                     02                      03

                                                  $913,403
                  litzi    $374,755                                       $0@53,04.3
              l@IEDIU,'-!   829,755                868,403                      043
              MINIMb@il     777,755                816,408                  856,043





                                                                (A Priv'leged Communication)
                                                                       I




                               REGIONAL MEDICAL PROGRAMS SERVICE
                            SUMMARY OF AN OPERATIONAL GRANT APPLICATION



             NEBRASKA  REGIONAL  MEDICAL  PROGRAM               RM 00068  5/71
             Nebraska  State  Medical  Association             April 1971 Review Committee
             1902 First  National  Bank  Building
             Lincoln, Nebraska  68508


             Program Coordinator:  Harold S. Morgan, M.D.
             REQUEST: This is an application for  status  as  a  new  Regional  Medical
                       Program, to  serve  Nebraska.  Requested  (3  years  beginning
                       July 1. 1971):
             Projects            ist  Year      2nd   Year   3rd  Year       TOTAL
             Core                 $394,670      $432,247     $440, 5@3     $1,267,570
             #1-C6ronary Care     195,174        189,562       -0-           384,736
               Training
             #2-Communications
                Facility          130,983        133,981       -0-           264,964
             #3-Mobile Cancer
                Detection Unit    129,23        133,801       -0-           263,094

             Direct Costs         850,120        889,591     $440,653      2,180,364
             Indirect Costs       179,104        187,925       98,042        465,071
             TOTAL              $1,029,224     $1 077,516    $538,695      $2,645,435


             FISCAL INFORMATION:  This region is currently part of the     Nebraska/So uth
                                   Dakota Regional Medical  Program  which  was  funded
             in the total amount $1,583,391 for core  and  three  projects  A  period
             of 18 monthsi ending June 30,1970.  Based  on  recent  budgets  for  the
             last six months, the current annual level  of  support  is  as  follows:
                 ects            Direct Costs        Indirect Costs          Total

             Nebraska              $790,070              $165.,424         $955,494
             Core & 3 Projects
             South Dakota          $210,430               $51,916          $262,346
             Core & part of
             Coronary Care
             Project
              Total              $1,000,500              $211,340        $1,217,840







        Nebraska
        Regional Medical  Program               -2-                   RM 00068  5/71


        Attachments include "Fundirig Summary" and "Current Annual Level of Su port",.
        both.for the Nebraska-South Dakota REgional Medical Program.
        South Dakota's planning Application for a separate RMP was reviewed
        by the February 1971 Council.  Council recommended approval in the
        amount $@799500 d.c.o. for the first year  ($259,500  for  core  and
        $120,000 for South Dakota's part of the Coronary Care project for one
        year only) with a level of cote support $313,000 the second.year and
        $376,000 the third  year.

        C,F,OGRAPHY AND DEMOGRAPHY:


          Chadron
            a


      Crawford

                                                                    Norfolk
     @scottsbluff



                                North  Platte
        Si(                     er                     and Is.

                                                                       Lincoln

                                                          gs



                                   Mc Cook
                                                     Red Cloud           Beatrice

        Nebraska, encompassing 76,712 square miles, is bordered on the     north
        by South Dakota, to the west by Montana, Wyoming and Colorado,     to
        the south by Kansas and to the  east  by  Iowa  and  Missouri.  Some
        characteristics of-the.1.5 million inhabitants are.  54% urban, 98% white
        and 30.2 years median age.
        Mortality rates per 160,000 are 385  for  heart  diseases,  161  for cancer,
        128 for CNS vascular lesions and 24.4 for kidney diseases.
        Health facilities include Creighton University School of Medicine, t e
        .University of Nebraska College of Medicine, 9 schools of medical technology,
        8 schools of X-ray technology,,l school of cytotechnology, 14 schools
        of nursing (R.N.) and 4 schools of practical and vocational nursing.
        According to the Journal of the American Hospital Association,
        Nebraska has approximately 116 registered hospitals with 12.,700 beds.
        Of these only about 48 have more than 50 beds, 24 have more than 100
        .beds and 19 more than 200.  Of the 14 teaching hospitals, all in Lincoln
        and Omaha, 9 are major teachin  affiliates of the two medical schools.
                                        9








            Nebraska
            Regional Medical Program             -3-                     RM 00068  5/71


            Within Nebraska, there are 1,683 M.D.s (118/100,000),  61  D.o.s  (41/100,000)
            and 4,653 active nurses (288/100,000).
            B-ACKGROUND: The development of the Neb.raska-South Dakota  Regional  Medical
                         Program began in the Fall of 1965 and a  request  for  planning
            was submitted in October 1966.  The  application  represented  individual
            planning programs by the Nebraska State Medical  Society,  University  of
            Nebraska Colleges of Medicine and Dentistry, University  of  South  Dakota
            Medical School and Creighton University School  of  Medicine.  The  November
            1966 Council recommended approval with an expression  of  concerns  about
            interrelationships of the five parties in planning and the apparent
            cumbersome administrative framework.

            The Nebraska-South Dakota Regional Medical Program  was  initally  approve
            for two years of planning beginning January 1, 1967.  A  site  visit  was
            made in September 1968 to assess the Region's  capability  for  operational
            status (core And four projects). The site  visitors  observed  that  the
            Region was in an early stage of  regionalization.  Two  deterrent  factors
            were the inability to complete major staffing until June  1967,  and  the
            need to create a new organizational structure to function  as  a  whole.
            Planning also seemed to be by intuition rather  than  by  design.  There
            was a lack of adequate data needed to  support  project  planning.  Coopera-
            tive organization between the three medical schools  (University  of  Nebraska
            College of Medicine, Creighton University School of  Medicine  and  the
            University of South Dakota) was noted. There  seemed  to  be  good'partici-
            pation by Nebraska physicians, but much less involvement  of  South  Dakota
            physicians. It was apparent that the  Nebraska  State  Medical  Association,
            the grantee institution, played a dominant role  in  Regional  affairs.
            The site visitors believed that although the rate of  progress  in  program
            planning and development was slow, there were beginning  signs  of  regionali-
            zation. It was also agreed that continued development  of  the  Region  would
            depend upon the initiation of some operational projects  to  provide  visi-
            bility and a focal point for the high degree  of  enthusiasm  displayed.
            In view of the site visitor's report, the Review  Committee  and  Council
            concluded that operational status was premature  and  recommended  approval.
            for continuation in the planning  phase.  Accordingly,  the  three-year
            operational applica tion was funded as a renewal planning grant.
            The Region applied for support for four operational projects  in  May  1969.
            A site visit followed in June 1969 to assess progress and  to  review  the
            projects. Changes in the bylaws seemed to  have  influenced  progress  toward
            regionalization. Major changes included: (1)  designation  of  the  Presidents
            of the two State Medical Associations to serve on a ternat  ng  years  as
            Chairman of the RAG; (2),Presidents Elect of  the  two  medical  associations
            to chair the Executive Committee alternating annually; and (3) RAG
            representation was broadened to include  minority  group  representation,
            volunteer health organizations and nurses (70 RAG members,  35  from  each
            state).  South Dakota, which previously was less enthusiastic about
            Jointiig with Nebraska as a Region., appeared to have adjusted and  was








          Nebraska
          Regional Medical Program            -4-                RM  00068  5/71

          participating on a more equal basis. The  three  medical  schoolo.continued
          to maintain cooperative relationships. Planning also seemed to  be  on  a
          more sound footing. Concurring with the site visitors,  the  August  1969
          Council recommended approval for operational status.  The Council,
          however, remained uncertain as to the real involvement  of.South  Dakota
          in this program which seemed to be a carefully balanced arrangement
          between the two Nebraska medical centers. Staff  discussed  this  with
          the Region representatives in negotiating the award,  emphasizing  the
          need for real program outreach - not simply representation on various
          committees. The Region received an award for core and  four  projects  in
          the current first operational year.
          The first concrete evidence of South Dakotals immense  dissatisfaction  and
          possible bteakway was in the spring of 1969 when Governor Farrer of
          South Dakota wrote.the Secretary, H.E.W., requesting p6@,saion to
          merge the South Dakota CHP and FM efforts.  A year later, Dr. Robert
          Hayes, then RMPS Associate Coordinator for South Dakota, in  a  letter
          (February 20, 1970) to the Director, RMPS formally announced South DAkota's
          intention to withdraw from the current two-state RMP and  establish  its
          own Region. Subsequent dialogue between RMPS staff, Dr.  Hayes,  and  the
          Region Program Coordinator I:e*-., to South Dakotals submission of a
          rreliminary.draft application in May 1970.
          A staff team visit was made July 15-16, 1970, for the purposes: (1) assess
          the possibility of keeping the two states together in a mutually acceptable
          functioning program and necessary mechanics; (2) if South  Dakota  still
          desired separation, obtain clarification and elaboration of  their  draft
          proposal, which was very general and inadequate; and (3) provide
          appropriate assistance. Part of the team visited key core  staff  and  a
          past chairman of the RAG in Lincoln, Nebraska, and joined the rest of
          the team in Vermillion, South Dakota.  South Dakota's intent to separate
          became crystal clear and Nebraska seemed ready to acquiesce.  RMPS staff
          reactions to South Dakota's draft application were discussed  in  detail.
          The July 1970 Council preferred not to consider South  Dakotals  separation
          and the establishment of their own Region in advance of a formal application
          and the regular review process. For this reason, Council  did  not  address
          a relevant question, whether or not South Dakota might Assume administration
          of parts of the existing three funded operational projects  to  Nebraska-
          South Dakota RMP.
          Upon receipt of South Dakota's formal application dated July  22,  1970,
          the applicant was advised that the issue of separation had to  be  taken
          up by the November 1970 National Advisory Council following a  visit  by
          two of its members. They were advised that the  application  would  then
          be processed through the regular review process, Review  Committee  in
          January 1971, and final consideration by the February 1971 Council.










             Nebraska
             Regional Medical Program               -5-                   RM 00068 5/71


             Because of the proposed division of  the  two  states,  a  supplemental
             application dated July 27, 1970  from  Nebraska-South  Dakota  RMP  for
             $4,616,825 support of 5 new projects for 3 years was returned.

             on the basis of the visit October 27, 1970 by  two  of  its  members,  the
             November 1970 Council approved the separation.  The report of the visit
             is appended.

             To provide interim support  for  Nebraska-South  Dakota  Regional  Medical
             Program's core staff and three projects (beginning date January 1), the
             current first-yea r award was extended for six months until  June  30.,  1971
             at the current level of support.

             The February 1971 Council recommended approval of South Dakotals planning
             application for three years including support of their part of the coronary
             care project for one year.  An award will probably be effective July 1, 197.1
             subject to funding restraints.

             PRESENT APPLICATION:  Support is requested for core for three years and
                                    for the continuation of three projects for two
             years.


             GOALS:


                  1.  To support programs at preventing the  development  of  illness  due
                      to Heart, Cancer, Stroke, Kidney and Other Related Diseases.

                 II.  To support the design., of better programs for health  care  of  the
                      patient in his own community with reference  to  the  diseases.11


             OBJECTIVES:


               11 I.  To design better methods for the exchange of health care data.

                 II.  To develop research in training  and  demonstrations  of  patient
                      care and to support more effective methods  of  the  delivery  of
                      health care.


              III.    To promote regionalization and  cooperative  arrangements  as  means
                      of reducing health care costs.

                 IV.  To work with areawide health councils and other health planning
                      agencies to develop programs necessary  to  meet,  provide  or
                      ameliorate the determined health care  needs  of  the  community.

                  V.  To improve and update the knowledge  and  skills  of  existing
                      community health practitioners through various techniques of
                      continuing education; training courses, demonstration programs,
                      seminars, traveling clinics and access to addio visual communication
                      systems.








          Nebraska
          Regional,Medical Program                                    RM-00068 5/71


             VI.  To encourage hospitals and nursing homes to. join in programs
                  of continuing education for in-service personnel in order that
                  these members of  the  health  team  be  brought  up-to-date  on  the
                  latest techniques  used  in  nursing  care  of  patients  with  heart
                  disease, cancer,,stroke, kidney disease and other related diseases."

          PRIORITIES 1971:

               I. Continuing education to be the primary activity.
             II.  Development of education programs in community hospitals.
             III. Improve comnunications'and coordination with other health
                  organizations.
             IV.  Assist in all possible manner, efforts of organizations, in-
                  stitutibns  and  medical  centers  to  develop  a  comprehensive  program
                  for the prevention, early diagnosis and treatment of renal
                  disease.''
          ORGANIZATION:  The application includes a list of current RAG composed
                          of  thirty-five  members.  However,  Nebraska   has   revised
          the by-laws.  A  new  roster  of  members  (RAG,  Officers,  Executive  Committee
          and Finance Committee) is to  be  provided  prior  to  the  April  1971  site
          visit.  The  President  of  the  Nebraska  State  Medical  Association  presently
          serves as Chairman of the RAG-.
          The by-laws, Approved by the RAG January 27, 1971, provides for the election
          of officers by the  RAG;  chairman,.vice  chairman  and  secretary  by  the  RAG.
          There is also a provision for an Executive Committee and Budget and
          Finance Cormittee.
          EVAL@UATION:  The  brief  description  of  methods  for  program  and  evaluation
                        speaks only to rating proposals.
          CORE: The request for  core  budget  for  personnel  in  the        Requested
                Central Office, Creighton University School of                First    Year
          Medicine, and  the  University  of  Nebraska  has  increased          $3943,670
          abo                         ffic'             tion  includes 12
             ut 19%.  The Central 0       e budget por
          professionals (10at 100%, 1 at 20%  and  I  at  @0%)  and  6 full-time
          secretaries.  Unfilled  positions  (5)  include,  a  program  planner,  a  nurse,
          a health educator, statistician and a secretary.  Central office personnel
          includes  project  management  personnel  of  the  Coronary  Care  Communications
          projects,  six  positions  at  approximately  $103,700.  This  transfer   was
          made as a result of the RMPS management assessment visit February 1970.
          Core staff at the Nebraska College of Medicine ($44,783) and Creighton
          ($40,448) consists of  two  professionals  and  one  secretary  at  each  of  the
                                                                     are  supplies  at  $24 200
          two medical schools.     Other significant budget items
          and travel at $41,000.







            Nebraska
            Regional Medical Program               -7-               RM 00068 5/71


            The foci of core activities has been the three operational projects.
            other activities have included a contract  with  the  Continuing  Education
            Department of the University of Nebraska to provide  a  series  of  telephone
            conferences in the two states and circuit courses.

            Nineteen telephone network conferences were conducted for  physician@g@,.@
            and nurses June 18 through December  15,  1970.  Two  additional  conferences
            were planned, but were cancelled because  of  poor  reception.  Nine  con-
            ferences reached a total audience of 471 physicians, an average of 52
            per conference.  Ten conferences reached a total audience of 1,144 nurses,
            an average 114 per conference. Post  conference  evaluation  in  terms  of
            subject interest broadcast quality, usefulness  of  information,  was  done
            by written inquiry.  Evaluation response ranged from 28% to 80%
            (average 59%).

            Six circuit courses were conducted in different communities   in   Nebraska
            and South Dakota with a total audience of 3 94  (average  attendance  66).
            Evaluation of two courses dealing with care of terminal patients, indicated
            courses effectiveness in behavorial change.

            Televised continuing education for dentists is under study.  one program
            sponsored by the Region and the South Dakota Dental Association was
            scheduled to be aired over the educational T.V. networks in both states.

            Some effort has been made to establish a  closer  relationship,  with  CHP
            A & B agencies, including a workshop initiated  by  the  N-SRMP.  A  series
            of joint conferences are being considered.  Sub-regions are to be developed
            where CHP agencies exist. Two "B" agencies are  now  in  the  planning  stage
            and two are operational.

            The core staff at Creighton are assisting the planning for that ingtitution's
            involvement in the Inner City Health Delivery Services, including the
            development of health centers.  This  program  includes  involvement  with
            the Omaha Department of Health, the CHP t agency,  and  the  Greater  Omaha
            Community Action Program.  These personnel were also involved in the
            dental T.V. program; a survey of heart disease in children; and organizing
            a four-day seminar on health careers management.

            The core staff at the University of Nebraska are interested in developing a
            curriculum for allied health training  at  the  University.  These  personnel
            also assist the University's component of the coronary care project.  They
            are also responsible for the coordination of  planning  a  kidney  disease
            program.

                Second year:  $432,247            Third Year:  $440,653







          Nebraska
                                                                  RX 00068  5/71
          Regional Medical Program
          Project #1 - Coronary Care Trai@n  -This  application          Requested
                       is for continuing support of  Nebraska's         First,Year
          part of the project for two years.  This project,              $195,174
          now in its first year, was approved for three  years,
          $443,647 the first year, $313,138 the second, and $167,871  the  third.
          As a result of study by the task force on heart disease,  improved  care
          for acute myocardial infarction patients was given the  high  priority.
          As a result, this project proposed coronary dare training  for  physicians,
          nurses and medical technicians in the Region, and to  offer  community
          hospitals technical assistance in maintaining equipment and establishing
          an information service. Its design was to offer  the  training  programs
          in sevaLal locations and by several modes to provide  maximum  access.to
          hos itals remote from metropolitan medical centers.  Thd@'project  was
             p
          to have the potential to train 220 physicians, 330 nurses and 12
          technicians annually. The present program  represents  the  cooperative
          efforts of six institutions as follows: Bryan  Memorial  Hospital  at
          Lincoln, Creighton University School of Medicine at  Omaha,  University
          of Nebraska College of Medicine at OmAha, University of South  Dakota,,
          Vermillion, S.D., St. Johnis McNamara Hospital at Rapid  City,  S.D.,
          and Sioux 'Valley Hospital at Sioux Falls, S.D.
          According to current revised budgets for the last six months of the current
          eight6en-month period, the current Annual level of support for the three
          institutions in South Dakota is $118,884 d.c.o. and $194,260 for the three
          in Nebraska.
          South Dakota Regional Medical Program has been approved for  support  of
          their part of this project at $120,000 for one.year.  The award, subject
          to fiscal restraints, will probably be issued to begin June  1,  1971.
          Reasons for the slow start are cited as lateness in the award  and  tooling
          up. Fourteen 4-week coursesl,were conducted for 251 nurses in  their  place
          of residence. -Evening courses reached 73 nurses.  The  ROCOM  system
          supplemented by physician lectures was rotated among 5 community hospitals
          for 61 nurses. Another program including a  physiological  and  phar-
          maceutical workshop were conducted in 12 hospitals for 226  R.N.'s  and
          40 physicians.  Five 2-day refresher courses were held for 174 coronary.
          care nurses. Five technician courses were attended  by  23.  Two  equipment
          workshops were held in different locations for hospital  personnel  were
          attended by more than 70 engineers, nurses and technicians from 17
          hospitals. 148 physicians participated in  fourteen  2-day  seminars.
          Project personnel visited 70 of (70%) Nebraska hospitals and  46  (70%)
          of those in South Dakota.
          ROCOM,teaching packages have been delivered to 18 locations, 9  in  each
          state and 667 have been recipients of this  training.
          Education by pre and post testing have proven to be  of  questionable
          value. Evaiuation of trainees performance six  months  after  training          .@--: I
          is now being done.                                                                 ,
            I  Second year;  $189,562           Third year:  -0-








            Nebraska
            Regional Medical Program            -9-                RM 00068 5/71

            Project #2 - Conmunications F   it - This project,         Requested
                        now in its first year, was originally          First Year
            approved for three years, $132,715 the first year,          $130,983
            $132,715 the second and $171,390 the third.
            South Dakota has indicated no interest in trying to divide the support
            of this project.
            The program is to develop a communications facility located in Omaha
            involving the facilities and resources of the local educational
            institutions: Creighton University, University of Nebraska Medical
            College@ University of Nebraska and several teaching hospitals.  The
            facility, as proposed, is to consist of four components:
               1.  A telephone access information system accessible to medical
                   personnel via a WATS line, a medical tape library service and
                   drug information;
               2.  resource for referrals;
               3.  information resource for information and assistance for
                   instructing materials;
               4.  audiovisual equipment supply and advice.
            The program, under the guidance of the project'administrator, is operated
            24 hours per day, 7 days a week.  The project line switch board connects
            Nebraska, South Dakota, Iowa and Kansas through a series of WATS lines.
            The drug information service received 390 calls.  Study of drug Adverse
            reaction reports is a secondary objective.  The media library staff have
            Accumulated some.library material and have visited 76% of the hospitals
            to assist in the development of in-service training programs.  A tape
            library located at the Nebraska @College of Medicine, became
            operational in January 1971 and will provide the service to practitioners
            in Nebraska, South Dakota and Iowa.  The project library now has 100
            tapes owned by the University of Nebraska and 90 owned by the N-SDRMP.
            Iowa is to contribute 150 tapes.

                 Second Year:  $133,981           Third Year:  -0-
            Project #3 - Mobile Cancer Detection Unit  Now in its          Requested
                         first year, this project was approved for         First Year
            three years,, $134,739 the first year, $128,739 the          $129,293
            second and third vears.
            The project proposed to provide an improved cancer detection program
            for the low socioeconomic families of Omaha served by the clinics
            of the two medical schools.  The mobile unit is to augment the existing
            clinic services, and is also to be available to rural concentrations of
            American Indiana.  Screening procedures include: oral, colon rectal,
            breast and uterine.  A study is to be conducted to evaluate the
            effectiveness of the simple screening tests and the automated history








        Nebraska
                                          -10-                   RM 00068 5/71
        R6gional Medical Program
        system.. The Communications Project is to provide backup on the question-,
        answer Iphase of the activity. A cancer detection  education  program  &E
        the U.N. was also planned.
        The mobile unit is reported to be udder construction as of January 17, 1971
        with delivery expected soon.  Two nurses, a sociologist, a biostatician,
        and a secretary have been employed. equipment  including  a  mammography
        unit* dental chair amd examining tables has been  acquired.  The  socio-
        16gist has done some work towards proposed service for lhdiansi  One
        nurse requiring additional skills was given training under the direction
        of the Chairman of the Department of OB-Gyp, Kafisas University  Medical
        Center.  Project principals visited the Kaiser Permanent Multiphasic
        Screening Unit in Oakland, California.
        Projected scope of work including caseload is not  specifically  stated.
               Second year:  $133,801             Third Year4    -0-









             Nebraska
             Regional. Medical Program                              RM 00068  5/71.1


                                  NEBRASKA-SOUTH DAKOTA FUNDING SUMMARY
                                                  RM   00047


                 PLANNING


                 Council -  November  1966


                           November   1968


                 Site Visit   September 1968

                 lst  Year                     I/l/67  -  12/31/67

                                Direct  Costs     $289,350
                                Indirect  Costs       60,989
                                         Total                         350,339

                 2nd  Year                     1/l/68  -  12/31/68

                                Direct  Costs     $281,450
                                Indirect  Costs      67.9.17
                                         Total                        $349,367

                 3rd  Year                     I/l/69  -  12/31/69

                                Direct  Costs     $440,375
                                Indirect  Costs       70,831
                                         Total  I/  2/                $511,206

                 Total 3 years                 1/l/67  -  12/31/69

                                Direct  Costs     $1,Otl,175
                                            ts       199,737
                                Indirect  Cos
                                                                    $1,210,912


            1/  The Region was initially approved and funded for two years of planning.
                U-non review of the three-year operational application, the Review Committee
                and Council concurred with the site visitors that operational status was
                rremature.  Accordingly, the three-year operational application was
                funded as a renewal planning grant carrying 6ommitments (d.c.o.) $350,239
                the second year and $738,832 the third year.  The Region became operational
                 beginning January 1, 1970, and continuation of core, reviewed by staff,
                 was funded for one year with a commitment the second year; core support
                 must be renewed for the third operational year prior to January 1, 1972.

                 The renewal ewstd  for the third year of planning included $107,880
                 ($102,520 direct costs and $5,360 indirect costs) for one year
                 additional planning of two rrojects, #2 - Audio Visual Continuing
                 Education Services and #3 - Coronary Care Program.  Project #4 -
                 Stroke Rehabilitation Technician Training - was disapproved.








      Nebraska
      Regional Medical Program                -12-                      RM 00068 5/71

           OPERATIONAL                      1/l/70     12/31/72

           Council - 1969 August    and    December
           Site Visit - 1969 June

                                                                           Direct Costs
                                                 Approved                               Approved
                                                Period             Funded             Future Level
                                          1/    2   years      (01)      $443,647     (02)    $425,903
           core                           -                                      1/   (03)         -0-
           #1   Coronary   Care                 3 years        (01)     313,138       (02)   313,138.
                                                                                      03)    367,871
           #2   Facility     CommuInications    3 years         (01)    132,715       (02)   132.,715
                                                                                      (03)   171,390

           #3   Stroke Education                Aproved     Not    Funded
                                                p
           #4   Neopiastic Disease              3   years       (01)    134,739       (02)   128   739
                                                                                      (03)   128:739

           TOTALS  as of December 28,      1970                   *(Ol)$1,024,239     (02)$liOOO,495
                                                                                      (03)    $668,000
           Note*   01 year award includes authorized       use of,carryover $23,,744 ($17,744
                   Core  and  $6,000  mobile  unit   #4)

                                           Approved   Not Funded

           #3 -.Stroke Education
                                        01,               02             03           Total
           Direct Costs                $187,350      $187,350            $187,350     $562,050


           TOTALS as of December 29i 1970  (01) $1,312,992  (02) -0-

                                                                     (03) -0-



           The 01 award was amended December 29         1970 to extend the period for
           six  months   with   additional   funds.   No future   commitments   were   made
           because of the decision to dissolve the current bi
                                                                      -state     structure
           and  form  two   separate   regions.


                                                                          0                                            1 .1



                                             NEBRASKA - SOUTH DAKOTA REGIONAL MEDICAL PROGRAM

                                                                RH    00047
                              Current Annual - Level of Support Based on Budgets for the Period 1/l/71-6/30/71

                              Nebraska                               So. Dakota                                   Total
                Direct        Ind.          Total          Direct         Ind.           Total       Direct        Ind.         Total
                Costs         Costs         Costs          Coate          Costs          Costs       Costs         Costs        Costs

   'ore
                $334,358      $77,430       $411,788       $91,546        $24,006        $115,552      $425,904    $101   436     $527,340

   'oronary
   :ore
   Iroject         194,260       34,896      229,156       118,884         27,910         146,794       313,144        62,806      375,950

   :Ommuni-
   -ations
   )roject         132,714       13,834      146,548                                                    132,714       13  834      146,548

   cancer
   lobi le         128.738       39.264      168.002                                                    128,738        39,264      168.002
                $790:070       $165:424     $955,,494     $210,430        $51,916        $262,346   $-1,000,500    $217,340     $1,217,840






       South Dakota RMP Site Visit        -14-



                               RNPS Vist.to South  Dakota


                                Vermillion, South  Dakota




       Date:  October,27, 1970

       Place:  School of Medicine, University of South Dakota (Vermillion)

       RMPS Visitors:  Bruce  Everist   National Advisory Council, RMPS

                       Clark  Millikan   National Advisory Council, RMPS


       Personnel from South  Dakota:

                       Dr. Henry Parrish, Acting Director (Program Coordinator)
                       South  Dakota Regional Medical Program

                       Dr. Robert H.  Hayes   State Health Officer

                       Dr. J. Patrick Steel, Radiologist, Yankton, South Dakota;'
                       Member, National Advisory Council, National Institute of
                       General Medical Sciences

                       Earl B. Scott, Ph.D., Professor of Anatomy, University of
                       South Dakota, School of Medicine

                       Dr. Robert Quinn, Past President, North Dakota State
                       Medical   Association

                       Mr.  William  Murphy, Executive Secretary, State Hospital
                       Association


                       Dr. Warren  L.  Jones

                       Mr. Richard Erickson, Executive.Secretary, South Dakota
                       State Medical Association

                      Mrs. Bertha Damm, Executive Director, South Dakota State
                       Nurses Association

                       Mr. Peter Zwier, Executive Secretary, American Cancer Society,
                       South Dakota Division


                       Dr.  Bruce  Lushbough

                       Mr. James R. Nordstrom, SDRMP Staff, 2() per cent







             South Dakota RMP Site Visit                15


                             Mr. C,.'Halt(,,r, SDRMP Staff,]OO per cent

                             Mrs. Schwab, SDRMP Staff, 100 per cent
                             Mr. Don Brekke, SDRMP Staff, 50 per cent (SDCHP Staff,
                             50 per cent)

                             Miss Gloria Hansen, SDRMP Staff, 100 per cent
                             Executive Assistant of President Richard L. Bowen, University
                             of South Dakota
                             Dr.,George W. Knabe, Jr., Dean, University  of  South  Dakota,
                             School of Medicine



             General:  Tlif, N(@braska-Sotith Dakota Re@y,ional Medical Program apparently
                       Login amiably in 1966 with what appeared to be a rational aT)proari)
             to rof,ionalization involving two  adjac.ent states.  Enthusiasm was apparently
             high in both states.  Some of the difficulties described at the time of
             our visit were:
             1.  The meetings were apparently held in Nebraska, and the South Dakota
             representatives had to spend considerable time traveling to  and  from  Omaha.
             Without adOquate airplane service, this meant a two-hour drive each way at
             a bare minimum.
                 Ideas were germinated in South Dalota and come to fruition in Nebraska
             with little substitute change.
             1.  Ptincinal core personnel were placed in the two universities in
             Net,,rael<a without simil.ar attention or recognition at the University of
             Sout Dakota.
             4.  As South Dakotans see it, they were treat(@d as country cotisins; made
             to fepl that they were lacking in sophistication  and   therefore, having
             to attempt to make up for this with sincerity, enthusiasm and dedication.
             5. The South Dakotans believe that there  was  inequity  in  the  distribution
             of funds.
             6.  A variety of other items described in detail.on pages 1P,, 19, 20, and
             21 of the printed now planning grant application for a South Dakota Regional
             Medical  Program.


             New  application:
             RMP-CHP relationship.  There is described an attempt to partially merge
             those two organizations. This was initiated by  the  Governor  with  a  letter
             to H.E.W. and was concurred in by the power structure  of  medicine  in  South
             Dakota.  This chanjle (from the traditional arrangement) is that the Regional
             Advisory Group will be identical for both organizations and that certain





       South Dakota RMP Site Visit            -16-


       individual employees may receive partial stipending  from  CHP  and  partial
       stipending form RMP (Mr. Don Brekke).  There  will  be-separate  offices  and
       separate directors for the two organizations. In  a  state  with  a  limited
       number of professional people, this arrangement would  seem  to  make  good
       sense, save time and allow for greater cooperation among all involved 'Persons.
       Currently, there is an A agency (annual budget  140,000  dollars)  and  one
       B agency that has not been funded (Rapid Cit@. In  the  budget  for  the  RMP
       planning grant application, it is proposed  that  six  representatives  be
       paid from the RMP budget but act as RMP-CHP  representatives  in  the  six
       regions of the state and that they initiate, as part  of  thpir  job,  the
       development of more B agencies. There is  precedence  for  this  in  West
       Virginia and Alabama. There need not  be  any  specific  difficulty  arising
       from this arrangement; the cooperative undertaking might  well  be  an  intet-
       esting experiment.
       Bylaws of the Regional Advisory Group of the South  Dakota  Regional  Me  ical
       Program,  On  the  face'sheet of.the application, it is  stated  that  the
       recipient of the grant will be the School of  Medicine,  University  of  South
       Dakota Vermillion, South Dakota. This  should  be  a  bit  more  carefull
                                                                               y
       defined in the body of the application as on page  23  "the  University  of
       South Dakota" is mentioned, rather than the medical school as  well  as  t  0
       matter on'page 28 of the "aopointment and dismissal  (Director  of  the  RMP)
       shall be made by the University of South Dakota" being of  concern  to'  the
       Dean of the medical school who wants to be  certain  that  the  distinction
       between the ov6r-all  university and the medical school is absolutely cleat.
       Proposed Core,  The  prospective use and activity of the core staff, for which
       budget support is requ6sted, is impossible to  evaluate  from  the  document
       given us. At the time of our visit to  Vermillion,  the  authors  of  the
       application stated that they ha.d originally planned to write  a  much  more,
       elaborate and detail-ed grant proposal but had been advised  by  staff  to
       delete all extraneous material. The  result  is  a  s.ynopsis of  a  synopsis
       and gives merely a listing of 16 professional staff  people  plus  10  other
       employees. We tried to discuss the duties  of  each  of  the  professional
       people and it became more and more evident  that  this  list  constitutes.
       an attempt'to bring a basic staff of public  health  professionals  into  the
       state. The list  includes:  a  biostatistician,  an  epidemiologist,  medical
       sociologist, and a community developer. It  apneared  obvious  that  if  these
       people can be found and employed, they probably would  wear  "r6any  hats"
       but would share a basic dedication to improving the  health  of  the  people
       of South Dakota. It was obvious that the actini,, director  of  the  proposed
       South Dakota RMP (Doctor Parrish) is public health  oriented  and  has  had
       experience in the mechanics of developing a foundation for h(,alth planning.

       We asked that the jot) descriptions of these 16 professional  people  be  sent
       to th, staff (in another document) prior to  the  National  Advisory  Council
       mc,etini,, November 9 and ].O.








            South Dakota RMP Site Visit                   -17-



            University  of  South  Dakota  Medical  School  relationship  with  RMP.  There
            apparently has been some uneasiness between the medical school and the
            Nebraska-South  Dakota  Regional  Medical  Program.  Dr.  George  W.  Knabe,  Jr.,
            the Current dean,  has  had  some  interest  but  little,participation  in  the
            Nebraska-South Dakota RMP and has  been  annoyed  by  the  RMP  demands  on  the
            time of the  medical  school  personnel.  Now  that  the  associate  dean,  Doctor
            Parrish, is the acting director of the South Dakot@a RMP, the dean is further
            annoyed by the amount of time  demanded  of  Doctor  Ilarrisn  in  developing  the
            new RKP.  Communication between the RMP personnel and Doctor Knabe has
            been faulty.  Doctor Knabe has not been privy to the development and
            content of the current proposal, and is somewhat uncertain about some aspects
            of the document but  does  endorse  the  participation  of  the  medical  school
            in carrying out  the  objectives  of  the  proposal.  The  dean  is  particularly
            interested in getting A full-time director of the proposed South Dnkote IW
            so that Doctor Parrish  may  return  to  full-time  activity  in  the  University
            Medical School. As  we  review  the  discussion  in  Doctor  Knabe's  office,  we
            feel there was more pique than substance in his uncertainties.

            Projects:  The  South  Dakota  group  of  the  Nebraska-South  Dakota  Regional
                        Medical Program has  apparently lost interest in the communications
            project and the  cancer  project  but  they  continue  to  be  vitally-interested
            Ln the coronary care project  which  has  approved  funding  for  a  period  of
            three years. The share  of  this  project  going  to  South  Dakota  is  $120,no@
  is        a year of which $50,000 funds activities centered in the University of
            South Dakota Medical  School  and  $70,000  funds  the  activities  centered  in
            Sioux 'Falls, South Dakota, and Rapid City, South Dakota.  From their
            description of the project's success  so  far,  it  would  seem  that  they  have
            made a significant  beginning  with  outreach  to  the  smaller  hospitals  for
            continuation and with courses of two days' duration at the University       '
            So far the instruction is primarily directed toward physiology, pharmacology
            and anatomy.  The  activities  centered  at  Sioux  Falls,  South  Dakota,  under
            the direction of Doctor Woods  appear  to  be  more  clinically  oriented  with  a
            demonstration type  coronary  care  facility.  The  entire  group  with  whom  we
            visited were unanimous  in  their  hearty  recommendation  of  need  to  continue
            tl)is project as they refer to it As the first tangible eviience of "action"
            by RMP in South  Dakota.  In  discussing  the  future,  it  appears  that  South
            DakotAns Ido not have any  projects  ready  for  immediate  submission  but  do
            have a portfolio containing  22  project  ideas  in  various  stages  of  develop-
            ment.  These  have  previously  been  discussed  by  the  Nebra0ke-Soutb  Dakota
            RMP Regional Advisory Group.

            Recommendations:


            1.  South Dakota   be designated as an independent RMP

            2.  Arrangements   be made.to supply "core  rupport"  of  at  least  $40,000  per
            year to tlit, new South Dakota RMP.    if further writ@t(-Ti (](@n(,riTition of plan.,;
            and of functions of the expanded core p(-ro;onn.-I              I)y South  Dakota
            in forwarded to   the RMP Waniiington-of"fl(-(@, ttit- stiff tit),l National A(Ivt,flory
            Council consider increasing the $40,Ono nnnital cort,  i,,,tipport  immediately.







         South Dakota RMP Site Visit


                                                                         inu--d.
             Funding of the coronary care orbject in South Dakota be cont
         $120,000 per year -- total time three years.

                                                    al status" as soon as an acceptable
         if.  South Dakota RMP be moved to "operation
         operational grant application is received and processed.
         -5.  Details of the separation of Nebrarks-South Dakota RMP into Nebraska
         RMP and SDRMP be constructed and carried out by the Washington RMP staff
         being certain that the NebrAska RMP receives appropriate funding in the.
         new arrangements.





























                                                              RMPS/GRB  12/8/70






                                                         (A -Privileged Co,,iiniunication)




                              SU@RY OF REVIEW AND CONCLUSIOiq OF
                                  APRIL 1971 REVIEW COMMITTEE


                               NEBRASKA REGIONAL MEDICAL PROGRAM
                                                   5/71


                        FOR CONSIDERATION BY MAY 1971 ADVISORY COUNC: IT



            RECO@,Rt--@DATION: Approval as a separate and new Region with  operational
                             status for three-years at the current level with
            conditions: 1) the concerns of visitors be re-communicated back to the
            Region; 2) the review of the second year  continuation  request  include
            a site visit to assess progress; and 3) the level of funding be
            increased if significant progress is achieved in the first year.

                                                   Direct Cost
                                         Requested              Recommended

            01                            $850,120                $790,070

            02                             889,591                 790,070

            03                             440,653                 790,070


            TOTAL                       $2,180,364              $2,370,210

            Because the Region did seem to be fully informed about the triennial
            process, the site visitors recommended more funds for the third year
            tentative commitment than were requested to enable the  Region  to  make
            reasonable program projections.  The specific amount recommended was
            based on NebrAska's portion of the revised budgets for  Nebr@iska-Soutli
            Dakota for the period I/l/71-6/30/71 as reported by staff.  The
            committee did not fully di:-,cuss the implications of the  recommendations
            for third.-year funding in the absence of the specific  request,  however,
            as in Western Pennsylvania action, the Committee assumed that new projects
            would,require national review and approval.
            LRI@UE: The Committee accepted  the  report  and  recommendations  of  the
                       April 1-2, 1971 site visitors,

            Ila4or questions by the visitors addressed the actual involvement  of  the
            RA.C, differentiation in the roles of the RAG and the grantee, core staff
            capability and the Region's potential as a viable operative change agent.
            Splintered relationships with South Dakota and very recent reorganization
            of Nebraska as a separate Region were taken into account in this assessment.

            New BY-Laws were adopted Jant,-ary 1971.. With tlir-@.exception of three
            designated members representing the State Medical Association, the RAG
            elects its own members and officers. Staff members  of  the  Re&ion  and




           Nebraska RMP                                2 -              PM 00068 5/71

           grantee institution may not serve as regular voting members of  the  RAG
           or its Committees. Since the present application was  submitted,  a  new
           RAG has been formed and is comprised of 29 persons.  Eleven (40'/.) of the
           RAG members are new and the new chairman is a consumer representative
           (lady rancher and former U.S. Senator).

           On the plus side, there are some positive features of N%MP.  These
           include strengthened relationships between the two medical schools  as  a
           result of involvement with the Region.  There are also good relationships
           between the Region, medical schools, and practicing physicians.  The
           coronary  care and the communications projects auger well for the Region.
           The visitors question the direction of the cancer mobile detection project
           as currently perceived by the @roject director.  Core  activities,  many
           by individual initiative rather than central design., include  assistance
           3-n developing neighborhood health centers, planning a health agency
           management course, assistance in heart sound screening, developing
           Al@lled health curriculum, and coordinating planning for a kidney disease
           program.

           Oa@the minus side, the operating objectives and priorities need to be
           better defined and understood by all concerned.  The  program  management
           needs to be substantially strengthened 1)  stronger  and  more  effective
           central program direction under a more skillful coordinator; 2) the
           role of RAG should be strengthened with clear operating  objectives  and
           procedures; 3) the role of the grantee should be redefined and
           separated from the RAG; 4) better utilization of available core staff
           resources in program planning, monitoring  and evaluation; 5) more
           effective utilization of resources in defining needs and program
           development; 6) organized plans for phasing projects into  other  funding
           mechanisms; and 7) strong involvement of Core and RAG in  directing  the
           mobile cancer projected



           Dr. Retry Lemon was not present during the discussion of this application.


                                                      RMPS/GRB/4/21/71





                                                                                                     ADMNISTRATIVE CONFIDEVTIAL


                                          DEPARTFAENT OF HF-,%LTH, E@DI-ICATIOI,41 AND WEL,FARE

                                                                  PUBLIC HEALTH SEP%VICE
                                            HEALT'-I SERVICE-S AND MENTAI- 1-iEALTH ADMINIST'RATION


               Date:  April  8,  1971
         Bel
             'v   to
            tin Of -.
                      Quick     Report     on     the      Nebraska      Site      Visit
            Subject:  April  1-2,  1971  (Lincoln,  Nebraska)

               7'g -  Director
                      Regional Medical Programs  Service

                      THROUGH:   Acting Deputy Director
                                      Regional Medical Programs  Service

                      1.     Site Visit Team:


                             Consultants


                             Joseph W.  Hess,  M.Di                                    Joseph W.  Sabatiers, Jt.i  M.D.
                             (Review Committee)                                        Director
                             Director,  Division            of Education               Louisiana Regional Medical Prog.
                              & Research                                               New Orleans,  Louisiana
                             Wayne State University
                             Detroit,  Michigan                                        Amos  P.  Bratrude, M.D.
                                                                                       Private General Practicing
                             Sister Anti Josephine                                     Physician
                             (Review Committee)                                        Otoak, Washington
                             Administrator
                             Holy Cross Hospital
                             Salt Lake  City,  Utah

                             Chairman


                             Rmps Staff


                             Miss  Carol M.  Larson                                    James  Smith
                             Continuing Education             Branch                   Regional Developmental Branch

                             C.  Rai Maddox                                            Luther J.  says
                             HEW Region VII,  RMPS            Rep.                     Grants  Review Branch

                   II.       STRUCTURE

                   The meeting was  structured along th--  lines  previously a                                uggested by  the
                   site visit  team.   Although the  6ntire r,,io-eting was  conducted  in Lincoln,
                   there was  a  good cross-8ecti6r@P.1 representative  group of about 42.   The
                   purposes  of the visit were managed  through  three major sessions  and  a
                   number of small group discussions with participation by appropriate
                   @persons.   The RIVS  "Program Review,Criteria",  provided  to both  the Region
                   and visitors prior  to  the visit,  served  as  8  check  list and outline  for
                   the official  site visit  report.








            peg a 2  Directors WS
            The first two sess-ons (5 hours) during the first  day  focused  on  the
            Region's organizational structure; the  decision  making  processes;  goal
            ob ectives and priorities, and  program  accomplishments  and  objectives,
            The discussions were further amplified in  less  inhibited  small  groups
            (2 hours); RAG, Medical Society and Hospitals and Health Interests.
            Participants represented RAG, Executive Committee,  Grantee,,  two  medical
            schools, practicing physicians, hospitals, CIIP,  nurses,  State  Health
            Department, project directors, volunteer  agencies  and  core,  There  were
            very few consumer representatives,
            The third session (2 hours) during the  second  day  centered  on.drganiza-
            tional Internal affairs including fiscal management, staff organization,
            functions,, and budget. Participants included  all  principal  staff  and
            the President-Elect of the 'NebrAska,Medical Association (also vice-
            chairman of the RAG and Executive Committee).  The visitors met privately,
            with two core staff members having obvious expertise in program planning,
            development, management and evaluation.
            The site visit was concluded with a feed-back session  (I  hour)  with  the
            coordinator and'three RAG  officers  One  officer  also  represented  the
            grantee. Recommended funds  were  tot  discussed.  The  Region  requested
            a visit by RMPS staff in about 6-8 months to  assist  them  in  appraising
            progress in light of the bite visitors recommendations.  A more general
            fe6d-back followed open to all interested persons6
             UMMARY: Major questions by the visitors  addressed  the  actual  in  olvo-
                      ment of the RAG, differentiation in the roles of  ttie,RAG,.,end
            the grantee, core staff capabiiit'y-a--n-d-"t-b'e-"Reg-ion's potential as a
            viable operative change agent.  Splintered relationships with South
            Da ota and very recent reorganization of Nebraska  as  a  separate  Region
            were taken into account it this assessment.
            lqdw By-Laxqs were adopted January 19710  With the exception of three
            designated members representing the State  Medical  Associ6tion,  the  RAG
            elects its own members and,officers. Staff  members  of  the  Region  and
            grantee institution may not serve as regular voting  members  of  the  RAG
            or it$ committees. One third of the new RAG  members  ard  new  and  the
            new Chairman is a consumer representative (rancher and former U.So
            Senator),  The Governor is liste8@a6 one of the ex officio members*
            On the plus side, there are some positive features of I,'RIIP..,Thece
            in lude strengthened relationships between the two  medical  sclio6lb  as
            result of involvement with the Region.  There are also good relationships
            betwedt the Region, medical  schools,  and  practicing  physicians.  The
            coronary care and the communications projects auger well for the Region,
            The visitots@que6tion the direction of the cancer mobile detection
            project at currently perceived by the project director,  Core activities,





           page 3 - Director, RMPS
                                          ather than central design,   include
           Many by individual initiative r
           assistance in developing neighborhood health centerso planning a health
           agency management course, assistance it heart sound screening, develbpitg
           Allied health curriculum, and coordinating planning for a  -"dney  disease
           program,
           On the minus side, the operating objectives and priorities need to be
           better defined and understood by all concerned.  The program management
           needs to be substantially strengthened; 1) stronger And more effective
           central program directiot under a more skillful coordinator; 2)  the  role
           of RAG should@be strengthened with clear operating  objectives  and
           procedures, 3) the role of the grantee should be redefined  and  separated
           from the RAG; 4) better utilization of available core staff resources
           in program planting, monitoring, and evaluation; 5) more effective
           utilization of resources in defining needs and program development;
           6) organized plans far phasing projects@into other funding mechanisms;
           and 7) strong involvement of Core and RAG in directing the  mobile  dancer
           projett.
           REC i@NDATIO'ilSt Approval As a separate and new Region  with  operational
                             status for three years at the current level with
           conditions:  l)-thdt the concerns of visitors are communicated back to
           the Region; and 2) the.review of-the second year continuation,request
           include a site visit to assess progress and 3) that the level  of  funding
           be increased if significant progress has been achieved.

                                                       Direct Costs

                                                  ested            Recommended
                01                            $850,120                $722,914
                02'                            889,591                 7221914
                03                             44@0,653                722,914
           Because the Region was not fully informed about the triennial process,
           more funds Are recommended for the third year teiiative commitment than
           were requested.
           The recommended amount is based on Nebraska'6 portion of the revised
           budgetp@'fbr,,Nebraska-South Dakota for the period 1/l/71-6/30/71 ($790,070)
                                         8.5 percent.





           p   ic Realt  Ad-yisc
           Otints Review Bratch







                                                                                                                                                   D  1.@'  A  l@@  T
                                                                                                                                                   I,.J.  SAYS  4/8/71
                                                                               S T T'@,,  V @i  T
                                                         4   B   S I.,





                                 V-T@ SIT 0


                                                                                                                                 C     s t:@ I  t@ LI


                        jc) s c@ -,@Oll   lie s s     I.!.  D.   Cha irm a n                                             P.  Br,@ti-Li(le,  1?4,.D.
                               r                                                                                (private  pr@ictic,4n    physician)
                        Detroit,  Michigan
                                                                                                                           W,@isliii-igtor,
                        Sister          Ann          Josephine
                        Salt       Lalte       City       Utah                                                  jos(Lrli  W.  Sabatier,               M.D.
                                                                                                                (I)ir.       Louisiana        fl,@IIIP)
                                                                                                                t@'ew       Orleans,        La.


                                                                                     S     f f

                        Miss       Carol       M.       Larson                                                  C.  Ray  Maddox
                        Continuinc,              'L'ducat-ic)n  Branch                                                               VI.1
                                                                                                                Kansas        City,         Mo.

                        James  Smith                                                                            Lutlier      J.  Says,  Jr.
                        Re@ional                    DevelopGiental                                                j@- c@ ri t sRe@-@7iew           Branch
                        Branch


                        NEBI,,'.A,Sl.,:A  rEPT?,EOE-.P,'@TATIVES


                        RAG

                        Mrs.  Eva  Bowring,  Chairman                                                           Rodi@er  D.    Mason,  M.D.
                        (ConsL,mer)                                                                             Vice  Chairman
                        Rancher  &         former  U.S.  Senator                                                Pres,  Elect.Nob.  M&d.  Assn.
                        Merriman                                                                                Practicing                    Phy.-G.P.
                                                                                                                G c,-)i. e ra    urr'erv
                                                                                                                kiccook,

                        14.  Pobert,Brung,-Ard,  Secretary                                                      Clarence         R.  Brott,  M.D.
                        Hospital                     Administrator                                              Immediate  Past  Chairman
                        Lincoln                                                                                 General                Practice
                                                                                                                Pres.,@@eb.  l@led.  Assn.
                                                                                                                Beatrlre

                        Joseph  1,1.  liolth@@us,  M.D.                                                         Robert  B.  Kugel,  M.D.
                        Dean,  Creighton  University                                                            Dean,  University  of  Nebraska
                        School  of  Medicine                                                                    College  of  Medicine
                        Omaha                                                                                   Omaha






                T@,IEBRASKA iz.74P                         -2-

                C. J. Cornelius, -LI.D.                                     Ri.cl@,,ard   Bridley, D.D.S.
                (@eneral Practice                                                   University of Nebraska
                                                                            .t
                Sidney                                                      Coll.ec,e of Denistry
                                                                                  C:,
                                                                            Lii:icol.n

                J. Ts"qiitney Kelley, II.D.                                 llc@,,iry D. Smith, @I.D.
                Practicing Phy.-Psychiatry &                                Director of Health
                Neurology                                                   State of Nebraska
                  n? l@i a                                                  Li.neoin

                Daniel M.    Miller,    14.D.                               Jean Doty, R.N.
                C'ii,nirinan.,        &                                     Representing Nebraska
                Finance Cotiii.,-ii.ttec-                                   Nut'ses.Association
                General Surg--rv                                            Director or Nursing,
                Omaha                                                       C2-c@i,@,liton Memori(,31
                                                                            St. Josephs Hospital
                                                                            O,- i in h -i


                Frank 11. Tanner, M.D.
                Practicing       Patholo,@ist
                Past Chairman of
                Past Pres. Neb. Me-@4. Assn.
                Lincoln


                Project  Persoi-i!-ic:l
                Henry M. Lynch, M.D.                                        Cancer Mobile -
                Project Director Cancer Mobile                              Mrs. Jane L,.i,.-ich, R.N.
                Professor of Preventative                                     Asst. Director
                Medicine, Creighton                                         Mrs. Anne K  s
                Omaha                                                          Social I,,Iorker
                                                                            Miss   Carol    Kraft,    R.N.
                Doctors Marcy ('@'CU)                                            -Gyn nurse
                and Morris (Co@-ilinunications)                             (All) Omaha
                   Pro4ect Directors
                are full time Core staff aembers

                Other Nebraska Rf?rresentatives

                Mrs.   Calista   C.    Hughes                               Adrienne OdgAard R.'ii.
                Director,   CHP    "All                                     Columbus
                Lincoln

                Wilber Kizer                                                Sister     P6schala     Noonan
                Hospital        Adninistrator                               Hospital         Administrator
                Bierwill                                                    McCook

                Sharon Ryan R.N.                                            Robert Ro lloutrie
                Auburn                                                      Dir. Cont. Educ...
                                                                            University     of     Nebraska
                                                                            College of Medicine
                                                                            (I-,i a l'i a









                  'I" Bl@ S K'
                  l,i 11  @   t@i  ',',P


                  Core Staff


                  Central office  (Lincoln)
                  I-larol,d S.            i@I.D.                                  Deane S. llar(,y, III.D.
                  Coordinator                                                     Deputy Coordinator
                                                                                  & Project D-'Lr., CCU


                  Geor-,-e L. l@,oorj4. s , Jyr . ) Ec,4. D.
                      0
                  Project Director                                                Darrell D.  Puetlow
                  Co.-,i@.111urlic8tion Facility                                  Adm. tsst.

                  Kerii:@c@th E.  Neff                                                      Sci:iellpel)er
                  Fiscal Adm.                                                     Deputy Fiscal
                  Executive Secretary                                             Adm.
                  Nebrasl,a l,,ed. Assn.                                          (E@-tiployee of crintee)
                  (grantee)

                  Core staff at Uriv. of l@ebr@-si@a Col@l.e@ye
                    of i4eTicirlc-l

                  J.  P. Toll.m-ar,, i',"..D.                                     Sally C"Iqpple
                  Associate Coordinator                                           Planning Asst.
                  and PlinnirL,, Director


                  Core staff at Cre4l,@l-iton School of


                'William W. I,,'ood3 M.B.A.                                       Hatt@l.c DeLapp
                  Associate Coordinator.                                          Plan,,i:Lng Asst.
                  and Planning Director

                  Part time from P4viPS funds

                  PTY@ZPOSF, OF THF- VISIT:   In response to Nebraska's initial application for

                                                 operational status as a separate Region,  the site

                  visit was conducted to assess program structure, achievements and capability.

                  Prior to the visit   P14PS documents "i@TiP Review Process Requirements and

                  Standards" and      "Program Review Criteria" were   rovided to the Region and
                                                                                  p

                  site visitors.   The visitors used the latter as a check list and as an

                  outline for this report.   At the outset, it-was made clear that the

                  site visit was also intended to be helpful to the Region.

                  qLI,2.,IARY:   The historical development of the Currently funded Nebraska

                  South Dakota Regional Medical Program was taken into account.









              q    S F
               @ f  ,A r&,P
              T'i-,c- long period oL' inertia due t@) tLi(@         relationships beti4eer,
              tlic- two states, an,:), the very curzeiit              efforts by IIc@br.;,ska

                      ognized and        c'i
              ,.7(,rc, rec         consi ered by the visitors.





              Although the entire           was conducted i.r,, Lircolii, there was a  good
              cross sectional representative ;rctjp of at-,Ou,c 42.  The meetin<Y was
              structured along the lines previously suggested by the site visit tean.
              The purposes of the visit were managed throu,,I-i three major sessions and a
              number of small group discussions with participation by appropriate persons.


              The first two sessions (5 hours) during the first day focused on the Regions
              organization structure; the decision making processes; goal objectives and
              priorities; and pro,-ra,-p accomplishments and objectives.  I"Lie Discussions
              were further amplified inmore uninhii)ite(Ys,-@nall groups  (2  hours),  RAG,
              l,ledic6i Society and Ilospitals and HL@altli Interests.  Participants represented
              RAG, Executive Cbn-nittee, Grantee, two medical schools, practicing
              physicians, hospitals, CIIP, nurses., state '.ealth Department, project
              directors, volunteer agencies,  and  core,.  There  were  very  few  consumer

              representatives.


              The third session (2 hours) duriLi, the  second  day  centered  on  the  cote
              staff Organization, internal affairs including fiscal management, functions,
              and bud et.  Participants included all principal staff and the President-
                      9
              Elect  of the Nebraska I-,Iedical Association (also vice-chairman of the RAG
              and E)@ecutive Co-ii,,,ilittee). The visitors met privately x,,4.tli two core staff








               iN'EBI'@,Sl,@A r@IIIP

               mep-Lbers haviri,-!, obvious c),.p,2rtj,se in       nlaiirij,,n,- r-', e v c, I o p,-@i c- i-i i,-
               management and e)ialuatiori'.     Tl,)e, Associatc@(I CoorOi.i-iotor foi.- the
               Creiohton and the project director for t.iiz Coi-d-i!,iiun@,c@,tions l@'acili.ty.



               'I'he site visit @,ias conclude(.!      t@@,7o fceci-I)acl,@ sessions  (i@@ hours)

               I)eainniLic, with the coordinator and three           offic(.,@i-.s. One officer also
               represented the c,raLitee.                   fuels        not discussed.      'i@, c
               !le-ioi,i requested   visit by 1 @PS E7it@iff in ibout 6-8 riiotitltc,  to  assist
               tlici.1 -i.ii         progress -in light of- the site VI-sitor's recocii-iiendatiolis.

               @lhe visit ended i..,,iti                        c)pc-,T-, to @,,ll iritcrest(.,ci 1)ersoi-is.
                                          general

               GOAI,S. OBJECTIVES AND PRIORITIES
               Though  congruent  with  the  law,  the  goals  are  too  general   and   do   not
               reflect an assessment of regional needs.  Also since the operational
               procedures are riot clearly defined, it is difficult to determine whether
               the goals Are significant in decision-making.


               The stated goals are:
               1) To support programs aimed at preventing the development of illness due
               to  heart  disease,  cancer,,  stroke,   kidney   and   other   related   diseases
               2) To support the design of better programs for health care of the patient
               in his own cor&nunity with reference to the above diseases.


               The operating objectives do not correlate very well with goals, nor are

               they specific enough or data based.

               Three of the six objectives can be construed as being derived from the goals,
               @namely: 4) to work with Area-wide health councils and other planning agencies
               to develop programs necessary to meet, provide or ameliorate the determined




             NEBRASKA PL@IP                -6-

             health care needs of the community; 5) to improve in.d update the knowledge

             and skills of existing community heFIth practitioners through various

             techniques of continuing education; training courses,  demonstration

             programs, seminars, traveling clinics and access to audiovisual-

             communication systems; and 6) to encourage community hospitals and

             nursing homes to join in programs of continuing education for in-service

             personnel in order that these members of the health care team be brought

             up to date on the latest techniques used in the nursing care of patients

             with heart disease, cancer, stroke, kidney disease and other related


             diseases.


             None of the objectives have an obvious relationship to goal no-1.


             Priorities seem to have been derived from tal,.ing the "federal pulse

             for the dollars" rather.tlian primarily from regi-c)Lia.1, needs.  Priorities

             No. 1 (continued education) and No. 2 (development'of educational programs

             in community hospitals) relate to objective 5 and 6. Priority No.  3

             (improve communication and coordination with other health organizations)

             relates to objective 4.


             There are three projects in the operational stage.  The coronary care

             training program relates to goal, 2, objectives 5 and 6, and priorities

             1 and 2. The inservice training program, the Regional Medical  Media

             Library and the telephone conference aspects of the communications

             project likewise can be justified under goal 2, objective 5 and 6, and

             priorities 1 and 2.  The mobile cancer detection project as currently

             conceived by the project director may relate to goal 1, but does not

             bear a close relationship to any of the objectives or priorities

             although some members of the RAG feel that it has potential a,,; a

             tool for continuing education and improved  atient care.
                                                       p







             NE B'W., KA RYIP                   -7-

             A number of Core staff activities rel.ate to objective i@4.  These include

             1) the efforts of core staff assisting with     d-evel,,,I-)ilietit of neighborhood

             health centers in Omaha, 2) establishing an effective relationship  with

             CilPi 3) assistance to Nebraska Heart Association in conducting d heart

             defect (cardiosean) screening program in two C,-)r@IlIlLinities (Omaha and 7

             4) coordination and planning for a kidney disease program, 5) developing

             a curriculum for the training of Allied Health personnel..  The latter

             activity relates more to the need identified in the 1968 survey than  it

             does to the stated goals or objectives.

             II. OPC,ANIZATION

             The new bylaws enclosed with the application were adopted January 27,  1971.

             The major change is that, with the exception of three designate members

             representing the Nebraska Medical Association (grantee), the RAG  elects

             its own members and officers. Also, staff is no longer eligible  for  voting

             membership on the RAG or its Committees.  Under the former N-SDRMP bylaws,

             the presidents of the two state medical associations served on alternating

             years as chairman of the RAG and pre8idents-elect served as chairman  of

             the Executive Committee.  Ex-officio members of the RAG shall be the

             Executive Secretary-and Speaker of the House of Delegates of the

             Nebraska State Medical Association, the Coordinator and Veterans Administration

             representative without voting privile4ges.  The visitors believed the

             latter should have a vote.


             Since the present application was submitted, a new RAG has been formed and

             is comprised of 29 persons, eleven (1@0%)of whom are new.  Physicians account

             for 50% of the membership.  Fourteen percent are consumers and thirty-six

             percent represent hospitals, organizations including voluntary and  official
             agencies, and health planners. The new Chairman is a lady rancher and







             of the Medi,cal Associ@,il,,"oi and t'@@e SE@cretary is a hospital administrator.

             These officers also         the iii@n     l,'IxecLiti@j(? Cc)n,,,iitt,-ee. Committees.,

             all fi.1l.ed, include a             Coit,,iTiittee, B,,iclget and Finance, Ad Iloc

             Study and Development for Diabetic E(lucatioi-i and Ad lioc Study and Development

             for Reiial Disease.   The former c'at-c.,gc)rical task force committees have  been

             eliminated in favor of ad hoc cc)i@iTIniLtees.


             The RAG has spotty participation of  key  recyioi-ial  groups  and  interest.  The

             visitors  question  the  advisability  of  simultaneous  membership  (dual  roles)

             by several members on the policy-m@king comriiittee of the grantee  organization

             and the RAG.  The newly reorganized RAG i.s too new to assess their operative
             effectiveness within t@e re@ion, but it does have potential.


             Technical review structure and process are inadequately defined.


             The Coordinator has not developed a strong sense of program direction and

            @toliesion. Though, a very  pleasant  man  and  a  respected  physician,  he  lacks

             the administrative skills necessary to employ the management techniques which

             are an essential  ingredient for an PIIP.  This i.s reflected in a core staff

             which is not functioning as a unit and are limited in their ability to

             function as a regional resource..


             The Core staff does reflect a relatively broad rn.nce of professional

             competence.  Some fairly substantial management capability exists bu       t

             is not being effectively utilized.  The balance between central and

             institutional  components  seems  reasonable  and  development  of  field  offices

             is in the planning stage.  Two of the ptojec    ts are field activities and

             have reached into   a number of outlying areas of    South  Dakota  and  Nebraska.






             NEBI)@Kli P@'IP                  -9-

             The administration of fiscal affairs bv tli(2 grantee and their auditors

            are in good order.   There is a continuous        of core @iri(i project s

             with monthly corf.1puterized reports to the grantee institution and 1,LNLP.

             Hoxiever, there is no evidence of parallel   management control  of project

             progress    -care.  The grantee institution seems to exert excessive

             interest in policy determination.


             Sub-regionalization plans appear to be along Cl.iP "b" lines but there is

             evidence of inadequate planning.  Necessary relationships with CHP
             and others relative to subre,-,ionalization are poorly defined. The Region

             plans to establish its first sub-regional office at Kearney.     our

             CHP"B" agencies have been funded.






                                                                      [Zi',l 0 0 0 6 8
            N,,@brasi,@@a



            Ill. Involvement of Re-,oLi-,,,e@@:

            Probably because the grantee organization is the I.,,If!dical Associ.,Ition,

            there is a good involvement of I)r@acti.cl-ri@, pliy-,ici.@itis and organized medicine.

            The team has the impression that the r(.,E;i-on's other health and related

            interests, institutions groups and            are not a.s actively involved.


            The involvement of the Nurses' lssoci,,iCic)i-i in the P,.,,,I-l has not been as

            effective as it might be.  Nurses have availed themselves of Coronary Care

                     . hov@ever, the Executive Secreta
            Training,                                 i:y of the !'el)rasl@. Nurses Association

            feels that the MiP should also focus on other aspects of nursing care, such

            as care of the cancer and strol,,e patient.  She al.so believes that

            more input concerning program content should be solicited from the nurses.

            The addition of a nurse to the core staff would be a @,7orthy consideration.

            The team was informed that the Associite Coordinator for the University

            of N6braska Medical School is actively involved in clirricul.um planning

            for allied health including new types, i.e., physician assistants.

            However, it appeared that the tore staff in teneral was not sufficiently

            aware of the needs for health manpower planning and development.


            The visitors were not impressed by  the effectiveness of the State Health

            Department's programs as they relate to l@IP.


            CliP  N Agency, and other health planning agencies, have limited their

            involvement in the RIIP to the institutional level in the Omaha area.







            Nebraska RIAP                                                         R@l 00068



            However, the Executive Secretary of CIIP h@is been appointed to the new


            RAG.




            Recently a Comprehe-,isive Health Association Agr-@ticy of O@ysha, a new

            voluntary non-profit corporati6n,has been registered in the state.  It

            will be interesting to  see  what  relationships  develop  between  RMP  CITP

            and the newly formed Agency.



            IV.  Assessment of 1-@eads  Problem    e-.c
                                      a-


            The only systematic identification of need'Ithat was produced for the

            site visitors was an opinion survey conducted  in  South  Dal,,ota  and

            Nebraska in 1968.




            The survey was directed to 3 groups of health professionals:  physicians,

            nurses and hospital  administrators.  All  3  groups  agreed  that  the

            principal. problems which need to be overcome to improve

            the tare of patients with heart diseases cancer and stroke were:



                      - the shortage of nursing personnel (40-507. of respondents)


                      - inadequate extended care facilities (30-447. of respondents)



            Following the above w6re@listed:


                      - Shortage of paramedical personnel (20-307.)


                      --Shortage of  acute  care  facilities  (Intensive  care  and









            NEBRASKA E-,-4P               -12-


            V Pl@61(rRtLT4
                                                       .Fs


            Core Activities of tire bi-state N-SDj'.@,IP, which began in 1967, are not

            impressive. and the reorganization efforts as a separate region have

            begun


            The Coronary Care and the Communications Facility projects have apparently

            been well accepted and merit continued support.  The site visitors have

            serious concern about the Mobile Cancer Detection project as currently

            conceived by the Project Director. Although some project  personnel  have

            been on board since August 1971, the equipped trailer unit was not

            delivered until late March 1971.  Some of the more knowledgeable RAG members

            believe this project has potential public and professional education values

            if its course is redirected.



            VI Evaluation

            The evaluation plan or strategy varies from project to project.  The Coronary

            Care Training project incorporates plans for evaluation of learning  both

            short term and long term.  Site visitors were told that there are plans to

            evaluate the impact of this activity on patient care and mortality  rate@

            but this aspect of evaluation has not been formalized As yet.


            The Communication project is quantifying utilization of the 4 elements of

            the project.  User satisfaction is also being assessed.


            The project director for the Mobile Cancer detection project has no

            organized plans for evaluation and core staff wore vague as to what  they

            were going to do about it.







             NEBPJISKA PliP                   -13-

                                          ,3sess at I.e@4st one person i%7itli the capab
             The core staff appears to po,                                         ility
             of assisting project developers in designing adeciti@ite plans for evaluating
             outcomes.  However, he is not being util4,.zed consistently in this fashion
             at the present tilde.  His only responsibility appears to be for the project

             of which he is the director.


             Members of the Rt@G clearly indicated that they art-,., not receiv@g adequate
             information to enable them to malte info.--g.@,ed decisions in a number of areas,
             including ongoing project evaluation.  This is a serious deficiency

             which demands prompt and effective action,


             The Core staff appeared to be reasonably ijell up-to date on the progress
             of individual pro4ects but the available iiiforv,lntion is not being passed
             on to the RAG.  There is a serious deficiency on trie part of the
             coordi nator in understanding the relationship between project development,

             project,, progress review program goals.


             The RAG identified the need for a "Resource and Development Cdmmitteell
             whose membership is as yet undefined, but -Qyhose function is to assist them
             in defining needs, developing proorams and projects, and providing ongoing
             evaluative data,  This committee is seen -.9 a potential mechanism whereby
             the RAG can be better informed and can exercise a stronger voice in

             management of activities in the region.



             COIICLUSIONS:


             On the plus side, there Are some positive features of NIU4P.  These include
             strengthened relationships between the two medical schools as result of





            N @.: BP, A S Y@ f k)", VI p      -14



            involvement @,ith the Region..  "i'llere a-re 6,' o gooj
            the Regicinl medical schools, ar@d proctici.r,@,           The coronary care
            and the copa-,iuriic6tio,,is projectc auger ,ic-11 for the Region. The visitors
            question the currE@','It, direction of the cancer mobile detection
              project.  Core activities, many by individual

                                                                  i- ri
            initiative rather ttian central design, incl.Liee,       ce in developing
            neighborhood health centers, p'laiinin@ a health agency franagement course,
            assistance in heart -ound screening, developing allic@d health curriculum,

            and coordinating planning for a kidney disease,


            On the minus side, the operating objectives and priorities need to be
            better defined and understood.  The program wtnage[r,-lnt needs to be

            substantially strengthened.


                A    There is the need for stronger and more effective centrAl. program
                     direction.  A stronger and more Itno@7I.edgeable program coordinator

                     is needed.


                B    The role of the RAG should be strengthened.  For example the RAG
                     should have a strong role in the selection and in the continuing

                     education of the Coordinator and Prooram Management.  The
                     following documents should be developed and officially adapted

                     by the RAG-.


                        1)  Mechanism of appointment of Committees

                        2.)  Objectives of each Cot--mittee

                        3)  Procedure for reallocation of furids'with NRNP







            ITEBRASKA T@,T




                        4)  procedures for                     o%ier procrro@,,is

                        5)  Procedures for )r(.iject

                        6)  Procedures for rr@iiect review
                                              1

                        7)  Procedures for project






              C    The role of -rantee organization should be redefined separately


                   from RtG.

              D - The capabilities of the already available resources on core staff

                   should be more effectively utilized in

                        1)  Program planning

                        2)  Program monitoring and evaluation

              E - Available resources should be.utilized more effectively in defining

                 needs and carrying this through to project operation.

              F - There shoul  be organized plans for phasing worthwhile projects

                   to other funding mechanisms.

              G -  There should be strong involvement of core staff and RAG in

                   directing the course of the mobile cancer project.




            REC  @ITDATI@iIS:

            Approval as a separate and new'Region with operational status for

            three years at the current level with conditions:  1) that the concerns

            of visitors are communicated back to the Regiot; and 2) the review of the

            second year continuation request include a site visit to assess progress

            and  3)  that the level of funding be increased if significant progress has

            been achieved.






               Msi@                        -16-







                 01.                            $850,1,20            $722,914

                 02                              889,59,L             722, 9@1.4

                 03                              4t4O@653             722,914



             Because the Pevion was not ftilly in@-orned about the triennial process, more

             funds are recommended for the third year tenative commitment than were

             requested.   This will allow the Pc!gion to make some reasonable program

             projections.



             The recommended ar@iount is based on Nebreska's portion of the revised

             budgets for IZebraska-South Dakota for the period 111/71-6/30/71 ($79OP070

             .legs the recent reduction of 8.5  percent.







                                   REGIONAL MEDICAL PROGRAMS SERVICE
                        SUMMARY OF A14 ANNIVERSARY TRIENNIUM GRANT APPLICATION
                                      (A Privileged Communication)


                 NORTH CAROLINA REGIONAL ]MEDICAL PROGRAM       RM 00006 5/71
                 4019 North Roxboro Road                        April 1971 Review Committee
                 P. 0. Box 8248
                 Durham, North Carolina 27704

                 PROGRAM COORDINATOR:  F. M. Simmons Patterson, M.D.


                 This Region is currently in its third operational year and is funded at
                 $2,691,394 ($2,191,873 direct costs and $449,521 indirect costs).  The
                 present application proposes:

                      1.  A Developmental Component;
                      2.  Continuation of core and 8 projects-,
                      3.  The renewal of 8 projects;
                      4.  Implementation of 13 new projects; and
                      5.  Termination of 3 projects.
                 The Region requests $4,635,902 for its fourth operational year,
                 $4,-367,113 for its fifth year and $4,321,835 for its sixth year.
                 Tables indicating breakout of funds requested for each project by year
                 are included as PAges 38-40.

                 A site visit to this Region was conducted on November  18-19,  1970.
                 (A copy of the report including the site visitor's recommendations is
                 appended.)
                 It is noted that the application includes a request for renewal support
                 for seven of the original operational projects, six for an additional
                 three years and one for one more year.  These include Coronary Care,
                 Trophoblastic, Central Cancer Registry, Tumor Tissue Registry,
                 Continued Education for Dentists, Continued Education in Internal
                 Medicine and Continuing Education for Physical  Therapists.  Of  the
                 eight projects with commitments seeking continuation  support,  four
                 are Also requesting renewal from one to two years beyond the currently
                 approved 3-year periods.

                 FUNDING HISTORY


                                          Planning
                 Grant Year               Period                      Funded  (Total)
                 01                 7/l/66-6/30/67                    $435,851
                 02                 7/l/67-6/30/68                     773,674





                   AROLINA RMP                       -2-               R14 00006 5/71
              NORTH-C

                                               operational.

                                                Planning
                                              Period'                     Fuftded (Total)
              Grant Year
                                          7/l/68-6/30/69                       $1,485,341
              01
              02                          7/l/69-6/30/70                      2,311,399
              03                          7/l/70-6/30-71                      2,691,394.
                                                                              *   355,975
              04                          7/l/71    6/30/72
                                          7/l/72-6/30/73                      *   156,526
              05
              *Commitments (direct costs) for,8 projects
              in the 4th year  and 2  projects  the  5th year
              North Carolina enc   asses 49,067 square    milks and  is  bounded  to  the
                                OMP
              north by Virginia, to the west by Tennessee, south     by  South   Carolina
              and Georgia, and east by the Atlantic ocean.  The capitol is Raleigh.,.
              Leading industries Iare textiles, wooden furniture, and bticks-.  Chief
              agricultural products are tobacco, peanuts, sweet     potatoes,, cucumbers.,
              poultry and fruits.  A  map  is  appended.
              The population is  5,082,000.  About  31%  of  the  population  resides  in
              the five metropolitan cities of A hville, Ch'rlottet Durham, Greensboro
                                                             a
                          and  Raleigh.  About  45%  of  the  population  is  urban.  The
              High Point
                 an age  is  29.5.
              medi
              Death rates per 100,000:    all diseases - 830, heart      304,   malignant
              115, vascular - 105, diabetes     15 and bronchio pneumonic       11.
              14edical facilities:  3 medical schools with an enrollment      of approximately
              901 (196 graduates), 40 schools of nursing (17 university       or  college
              based), 14 schools of medical technology,, and 7 schools of cytotechnology,
                                       ools,  28   schoo Is
              37 practical nursing sch                    of  kidiology-!technology   and
              2 schools of physical therapy.
              There are 155 n6n-feaeral hospitals with 31,724 beds and      9 federal with
              .3,637 beds.  of these,25 (includes 4 federal) have AMA approved intern-
              ship and residency programs.
              Professional.manpower:  4,484  active  physicians,   21   osteopaths,   210
              physical therapists. 200 medical social workers., 1,570 dentists,
              12,126-active registered nurses and 65 occupational therapists.
              HISTORICAL DEVELOPMENT:  Upon enactment of PL 89-239 in 1965, the
                                         NCRMP was initiated jointly by the Deans of
              Bowman Gray  School  of  Medicine,  Duke  University  School  of  Medicine,
              the University of Morth Carolina Schools of Medicine and of Public Health,
              and the President of the State Medical Society.  Soon thereafter,
              representatives of other major health institutions and organizations
              were involved in the Region's development.





                 NORTH CAROLINA RMP               -3-                IU4 00006-5/71
                 The initial application for planning for two years beginning July 1, 1966
                 was approved by the June 1966 Council.  Two site visits were conducted
                 in the planning phase. The Nov#mber 1966 site  visitor's  overall
                 impression was that the Region was well-qualified and that  enthusiastic
                 leadership was directing its program.  The November 1967 site visit
                 was made to appraise the Region's capability for operational status
                 (core and nine projects).  The visitors recognized a lack of an
                 overall state plan. Project review seemed sometimes  governed  by
                 political desirability rather than absolute standards of excellence.
                 Program development  however, was in the early stages and corrective
                 resources were available.  It was noted that the Evaluation and
                 Research Division of core staff played a valuable role in preparing
                 regional surveys and in providing baseline data for projects under
                 development.
                 As recommended by Council, February 1968, the Region became  operational
                 and received awards for three years. During the first  year,  $1,485,341
                 was awarded for core and 15 projects.  During the-se o@  year,
                 $2,691,394 was awarded for core and 22 projects.
                 Continuation applications for the second and third years were reviewed
                 by RHPS staff. In both cases it was believed  individual  project
                 progress reports and future projections lacked sufficient detail.
                 Core staff reports, however, indicated more had been achieved than
                 was reflected in the individual reports.  Major concerns were:
                 1) the continued data gathering activity and its costs as opposed
                 ,to unmet needs in health care at the grass roots level and 2) roles
                 and relationships one to the other of the Executive Committee, the
                 Board of Directors and the RAG.  Based on RAG and Core reports, the
                 reviewers believed that there was evidence of significant progress.
                 .ORGANIZATIONAL STRUCTURE:  There are two governing bodies, the Board of
                                            Directors (20 members) and. the Advisory
                 Council (RAG) (36 members). The Board has final  authority  for  program
                 operations and meets monthly.  A seven-man Executive committee may
                 exercise the authority of the Board in the management 6f the Association
                 between meetings of the Board.  Ufficers of the Board consist of a
                 6hairman, Vice dhairman and secretary.  The Chairman also heads the
                 Executive Committee.  The RAG had the responsibilities of reviewing
                 projects and advising,as to program direction and priorities.
                 Committees-  Heart (19), Cancer (19), Stroke (12), and Continuing
                 Education (13).
                 There has been some co nflict between the two governing groups  in  terms
                 of roles and responsibilities. The Region  is.now  exploring  the
                 possibility of reorganizing into one governing body, the RAG.
                 The project review process is under study in an effort to make it
                 less cumbersome. Currently the procedure begins  with  a  summary
                 application to core and the Executive Committee.  If in the opinion
                 of these two groups, the proposal is consistent with NCRNT program








                                                                      RM 00006 5/71
                NORTH CAROLINA RNP             -4-
                emphasis, it is presented to the Board. The project director is
                then notified that his project concept is in keeping with NCRMP
                               a asked to submit a full proposal, taking into
                .objectives and i
                consideration suggestions by the reviewers.  The-fully developed
                proposals.are reviewed by core, appropriate categorical committees,
                the Executive Committee, the Board and finally by the RAG.
                Functioning Committees for Heart, Stroke and Continuing Education
                (63 members)i develop program ideas based on data, and gi e program
                                                                        v
                advice from a technical, professional and cost benefit'standpoint.
                F. M. Simmons Patterson, M.D., former core staff director of NCRMP's
                Cancer Division, succeeded Marc J. Musser, M.D., as Coordinator in
                February 1970.  Subsequently, staff reorganization has occurred.
                Core organization and activities are discussed further in this
                summary under "Oresent application".
                GOALS, PRIORITIES AND STRATEGY:  The planning phase focused on the
                                                following steps to implement the
                PL 89-239 legislation in North Carolina: 1) establishing effective-
                communication between the various groups concerned with health
                care, 2) establishing a mechanism for self-evaluation and for a
                continuing survey of the effectiveness of programs begun, 3) initi-
                ation of-a program of post-graduate education at a variety of
                professional levels, 4) improvement of patient care through strengthening
                of medical center-community-hospital relationships, 5) moving toward
                a mo re complete integration of the entire system of voluntary medical
                care through improved communications, improved flow of records and
                improved use of modern technology.
                The operational goals have been along the lines of the basic legislation
                to develop categorical programs and strategies to control heart disease,
                cancer, stroke, and related diseases.  One of the first efforts was
                a fourzpart study: 1) education, 2) manpower, 3) hospitals and
                facilities, and 4) categorical disease patterns.  Six medical service
                catchment areas were identified, in which ad hoc study groups assessed
                the data, documented local health needs, and made recommendations to
                the Region.  Common denominator needs were: increased medical manpower,
                'better hospital care, professional and public education.  Supplemental
                information for the area study groups was provided in position papers
                on the four study subjects.  Beginning with a two-day retreat in
                April 1969, efforts began to develop priorities, revise guidelines
                .and assess the NCRMP composition in functions and structure.  During
                mid 1970, the RAG and Board jointly agreed to four basic areas@.. for
                emphasis: 1) improved care for specific categorical diseases;
                2) regionalization of programs; 3) health manpower development
                (continuing education, upgrading skills and developing new types
                and use of manpower); and 4) utilize local initiative in developing
                programs and cooperative arrangements.





                NORTH CAROLINA RMP              -5-                 R14 00006 5/71
                SUB REGIONALIZATION: The NCRM Program  is  being  sub-regionalized,
                                      but not on rigid geographical lines.  The
                Govtrnor has designated 17 regions for planning purposes for  state
                agencies.  The NCRNP, however, relies on the six catchment areas
                identified in their health survey study.  The large areas conform
                to natural medical referral patterns.
                EVALUATION: Project monitoring includes periodic review  by  core  staff
                             and categorical committees, as well as site visits.
                Evaluation of projects is done by a team located at the  University
                of North Carolina and funded as a part of the  Core  budget.  Evaluation
                services art available to project personnel during the  development
                and actual conduct of programs.
                COOPERATIVE EFFORTS WITH CHP AND VA:  The Region reports that
                                                      significant progress has
                been,made in formalizing a working relationship with CHP.  The
                application includes two documents: 1) joint statement of relation-
                ships between the NCRNP and NCCHP; and 2) proposal for  strengthening
                ties between the Governor's Advisory Council on Comprehensive  Health
                Planning and the Board of Directors of the Association for the.NCRMP.
                The hospital director of the Veterans Administration Hospital at
                Durham has been appointed to the RAG.

                Ail
                               As a health care leader with wide involvement, the
                               NCRMP has accumulated a vast amount of data.'for
                planning and action.  The Region has become the vehicle by which
                most health related groups in the state Are cooperating  in  identifying
                and acting upon health problems. Since the operational  phase  began,
                24 projects were funded including 2 that were renewed.  Twenty of
                these are currently ongoing,  A chart visualizing these project
                components by categories and program types is included on pages  36  37.
                Other activities include cooperative rural health efforts with
                CHP "a" and the Office of Economic Opportunity, and programs for
                the inner city poor. Through the efforts of core staff, CHP 314  "ell
                funds have been obtained for a Durham neighborhood health center  and
                current-efforts with a CHP "b" agency to develop an  ambulatory  primary
                health care center in the Charlotte Model Cities neighborhood.
                The Region has consistently reviewed its course of direction and
                methods, and made necessary changes.  This is evidenced by the
                reorganization of core during the past year, and current efforts
                to reorganize the Board and RAG into one governing group,.
                The appended site visit report addresses the Regions progress,
                strengths and weaknesses.








                                                                      IRM 00006 5/71
             (,NORTH CAROLINA R14P             -6-
                PRESENT APPLICATION: This  is the NCRMPs-first application under the
                                      Anniversary review sytem.  The proposal represents
                their initial request for support for the ensuing three years (04,0-5,
                And 06).  The amount of $3,875,178 (d.c .o.) is requested for the
                fourth year for continuation of core, a developmental component and
                29 projects (8 continuing, 8 renewals and 13 new).  In  the  fifth  year,
                $3,591.384 is requested for core, developmental and 25 projects.  In
                the sixth year, $3,559,498 is requested-for Icore, developmental and
                22 projects.
                All except three projects have been  ranked  1-26.  Those  inadvertent  y
                .not included in the rank order.are.projects #3R  Diabetic  Consultation,
                #SR Medical Library, and #19  Physician  Assistants.  The  rankIorder
                list is appended.
                Because of the recent site visit  and  although  there  are  "comitments"
                for a few projects, this triennial application is to be reviewed as
                a whole by the Review Committee and Advisory Council, and staff review
                of the continuation portion was  hot  believed  necessary.
                Developmental C    nent                                  Requested
                                                                         Fir t Year
                Priority will be given to support of those               $200,000
                activities that relate to regionalization,   health manpower
                development, cooperative arrangements and   demonstrate  local
                initiative, and those categorical disease   activities which have
                been given priority.
                Some activities currently under consideration  which  may  merit  support
                by these funds are: 1) 6xperiment-in a health care delivery demon-
                stration; 2) development of innovative patterns  of  rural  health  care;
                3) assistance to colleges and technical institutions in designing
                curricula for training allied  health  personnel;  4)  feasibility  study
                of ways and means of providing current drug information to physicians;
                5) purchase of two additional ROCOM audio visual machines for use
                in continuing education of.allied health personnel at the community
                level; and 6) develop and publish  diet  instructions  for  persons  with
                kidney disease.
                Applications for developmental funds will be acted upon by the RAG.
                It is anticipated that the review process will be about six weeks.
                  Second year:  $200,000                  Third Year:  $200,000
                Core  The budget reflects a moderate 4%              Requested
                       increase.  As in the past, it is             First  Year
                sub-divided into three categories,                    $694,021
                Administration, Institutional Coordinators, and
                Research and Evaluation Division.





                                               -7-                  KK 00006 5/71
                NORTH CAROLINA M
                      unt of $414,322 is requested  for Administration (headquartttt)
                The amo
                personnel.  Positions number 30 (18 professionals - 4 part time at 13%
                and 12 secretaries).
                For Institutional Coordinators $81,992 is budgeted for  4  part-time
                professional positions (196% time) and 3 secretaries (250%)  at  the
                three medical schools and one school of public health..
                For the Research and Evaluation Division, $103,207 is requested for 10
                positions (7 full time and 3 part time at 143%).  This.@,-group is located
                at the University of North Carolina Division of Health Sciences.
                Since the new coordinator was appointed, a reorganization  of  staff
                along functional lines has resulted in the following divisions:
                1) Administration and Management, 2) Planning and Development,
                3) Professional Services, 4) Continuing Education, 5) Hospitals
                and Institutional Services, 6) Communications and 7) Research and
                Evaluation.
                Core services have included staff backup for committees, as well as
                assistance and consultation to grant applicants,  ongoing  projects,
                and health-related organizations and professionals.  Feasibility
                studies included two of health care needs in an Appalachian mountain
                community and the eastern Albemarle Sound Area;  continued  planning
                assistance with the State of Franklin (7coaunties); and a  study  of
                allied health manpower.  increased emphasis is being placed on
                evaluation.
                Core staff assumed prime responsibility for coordinating plannin
                                                                                   9
                for the new Lincoln Neighborhood Health Center, serving a high density
                Negro area in Durham.  This project was funded in excess  of $1,000,000
                through CHP 314 "el' funds. Staff has also worked with the CHP  "bli
                agency in Mecklenburgh-Union counties to develop a primary care area
                of Charlotte. Aid is also being given to obtain  OEO  funds  for  an
                Appalachian rural health care program.
                Departure from strict categorical programs in future  activities  is
                indicated.
                Relationships with CHP agencies have quickened as is indicated by the
                joint statements included in the application.
                   Second Year:  $763,423              Third Year:  $839,765







                                             -8-                            5/71
                 CAROLINA IRMP

             CONTINUATION'PROJECTS
                               r4 Care Training and Development
             Project #2R Corona.-
                                                                     Requested
                                                                     First Year
                                                                    79-4, 60 5

                                                    ted by P14P f or three years at
             lonked 4th, this project has been atippor      of $23,584 for a 4th
             an annual level of $93,663 and has a commitment
             period.  Funding for tw'.additional years, for a total of six years is
                                   0
             now requested.
             This i.s a project to upgrade coronary care by training and developing
             cooperative activities among university medical centers, medical educators
                                                                                      31
             community physicians and nurses; as'well as offer consultation to hospitals.
             A computer-based system of medical records was to be eventually developed.
             Prior to the project, only 7 CCti's were operating.  There are now 62 in
             operation,and 23'additional units in the development or construction stage.
             Specific objectives:
             1.  Train nurses  96 in the current triennium and 64 more during th.enext
                 two years;
                 Train physicians  40 in the current triennium and 40 more during  the
                 next two years;
             3.  Provide consultation to all hospitals requesting assistance;
             4.  Develop a system to provide data required to evaluate efficacy of the
                 project approach and impact on patient care;
             5.  During the second trienium)  establish training programs for coronary
                 care nurses in each of the State's 17 planning areas.

             Progress:
             1.  160 nurses from 71 hospitals have been trained leading to 18 local
                 training programs.
             2.  Consultation services given to a total of 172 including architechutal
                 and electronic, nursing, medical, administrative, and medical-legal.
             3.  Sixteen hospitals have been established as clinical training sites
                 for nurses
                              Second Year                        Third Year
                              794,564                              $73,747




                NORTH CAROLINA RMP              -9-                   RM 00006 5/71

                Project 3R  Diabetic Consultation
                                                                    Requested
                                                                    First Year
                                                                    $62,550-
                The amounts requested agree with.those committed by RMPS.  This project
                now in its third year inadvertently was not ranked.
                Prior to this project, there was no organized effort in North Carolina
                for diabetes professional and public education.
                The overall goal of this project is to develop a broad education
                professional and public education program which can be continued by the
                State Diabetes Association After RMP support terminates.
                Progress to date: publications developed for physicians, nurses, and patients.
                Four teaching sites for nurses are in various stages of development.
                Edutationa  programs presented: 2 to 40 physicians, 33 for 1792 allied
                health personnel, 1595 person-to-person contacts with patients and/or
                their families, and 6 public education programs for 251.

                An evaluation component is described.
                                 Second Year                        Third Year
                                4@2,3676                                -0-
                Project 5R  Medical Library  Extension Service
                                                                    Requested
                                                                    First Year
                                                                    $24,039
                @.e amount requested is in line with the RMPS commitment for its 4th
                year. The project was not tanked by the Region, but  addresses  the  need
                for providing time the pressured medical profession with easy  access  to
                information. The project aims to encourage, and assist  in  the  develop-
                ment of good local medical libraries, as well as providing inter-library
                loans and reference service.
                There has been a 36% increase in inter-library  loans.  Hospital  library
                clients has risen from 32 to 85. Thirty-four percent  of  original  pilot
                group of 50 physicians continue to use the service.4 Consultation was
                given to 16 libraries.  Supporting hospital libraries supplied 820 items
                from their duplicate fil.e8 to 23 hospital libraries. A 581  page  second
                edition of the N. C. Union List of Bio-Medical Serials was printed and
                is now being distributed.  Announcements of workshops have failed to
                muster sufficient response to justify follow through, but efforts continue.
                                 S con   ear                         Third Year
                                    @0-                                 -0-










                                                                   RM
                                            10-                     ..00006 5/71
            NORTH CAROLINA RMP
            Project 17R Region   Center for Trophoblastic Diseases
                                                                    Requested
                                                                    First Year
                                                                    $53,485
            This project is now in its second year with an RMPS commitment of $29,000
            for the third year.  The request is requested for continued support-in
            the 3rd year and'renewal for two additional years.
            As stated in the Region s covering letter, the project serves  eleven,
            Southeastern states and may qualify for multi-regional support if such
            ,funds (910 title IX.) became available.  RMPS's in 8 of the states have
            submitted documented support to NCRMP.
            This project, rated 15 on A scale of 26 by the Region, was originally
            f nded by the National Cancer Institute.  RMP support was to allow the
            u
            center to expand through the application of newer testing  techniques
            involving radioimmunoassays of human chorionic gonadotropin (HCG)
            Funds were to be used for initial equipment and some increased staffing,
            It is reported that since the Center began, it has provided "translation"
            of new and experimental techniques for therapy into a practical method
            to diagnose and treat trophoblastic malignancies.  Also reported,  is
            that community physicians now have the facilities, HCG assays, and con-
            sultative assistance to expect to cure over 90% of such patients, even
            if metastases are present. During the next three years, expansion of
            the facility and greater services are anticipated.
                            Second Year                         Third Year
                             $49,321                              $51,1 8@

            Project 18  Tumor T ssue  Registry
                                                                Requested
                                                                First Year
                                                                -$6,631
            This project ranked 14 on the scale of 26 and is currently in its 2nd year.
            The amount requested for the 3rd year is in keeping with the commitment;
            no support is requested for its continuance beyond  then.
            Addressing the needs of pathologists in the field of oncology, the
            objectives or the project are essentially education.and consultation.
            The site for the registry is the Moses H. Cone Memorial  Hospital  in
            Greensboro, N. C.
            The project presents an annual seminar for the Pathology Section of the
            State Medical Society.  Seventy-nine pathologists are participating.






                                                                     RM 00006 5/71
                NORTH CAROLINA RMP               -11-
                Fifty-nine cases were distributed, 350o slides.  Sixty-five pathologists
                have contributed cases.  Most of the participants are from outside the
                university centers.
                                 Second Year                         Third Year
                                    -0-                                 -0-

                Project 19   Physician's Assistant Training Pro @am
                                                                     Requested
                                                                     First Year
                                                                     $169,662
                This project now in its first year addresses the problem of skilled
                medical manpower shortages, especially physicians.  The objective of the
                program is to develop well-trained and educated assistants at the in ter-
                mediate professional level, who by working with physicians, can supplement
                their services and reduce the present physician manpower shortage.
                The Physiciaes Assistant Program is designed especially for ex-medical.
                corps(nen; applicants with two or more years of college are also considered.
                The 24-month training program includes a core curriculum and clinical
                rotations.  Because support other than RMP was obtained for the program
                at Duke, part of the funds are being used to support a similar program
                at Bowman Gray.  Physician Assistants at the latter, are trained in
                various specialty areas, including family practice.  The program at
                Duke in addition to expanding its enrollment, has plans to extend the
                program to other institutions and evaluating the usefulness of the
                physician's assistant.
                Seventy-five students (45-Ist year  and 30-2nd year) are currently enrolled
                at Duke, which has graduated 42.
                Bowman Gray has 20 students currently enrolled (12-ist year and 8-2nd
                year).  Specialities: Pediatrics, 10; Obstetrics, 1; Surgery, 1; Urology,
                1; Family Practice, 7.
                A bill supporting this new type of manpower was to have been acted upon
                by the State Legislation in January 1971.
                The Duke University Board of Trustees gave final approval for a Bachelor
                of Health Science degree, expanding the career opportunities for physician
                assistants.
                                  Second Year                        Third Year
                                    $114,,220                            -0-







                                              -12-                  M.DoOO6  5/71.
              NORTH CAROLINA RMP
              Project 22  Oncology Chemotherapy Program
                                                                  Requested
                                                                  First Year
                                                                  $86,860
              The project has been ongoing for two years at an approved level of
              $78,000 each year.  It is ranked 23 on the scale of 26.
              This activity addresses the need for continuing education in the  use  of
              chemotherapeutics for treatment of patients with neoplastic disease.
              The purpose of the project is to offer practicing physicians aft intro-
              duction to basic oncology and the chemotherapy of malignancies.  This
              includes information on the biological behavior of neoplastic disease
              and the pharmacology of agents as the basis of diagnosis, classification
              and therapy.  The conduct of chemotherapy is conducted with the guidance
              and consultation of oncologists familiar with the form of'therapy.
              Reported progress includes the development of protocols for carcinoma
              of the breast, lung and colon. Analysis of clinical  data  continues  and
              is 75 percent complete.  During the first two years 140 physicians repre-
              senting 300 cases have participated.  Activities include a survey of
              physicians attitudes and of the therapy of decea.sed patients with
              carcinoma of the breast.
                               Second Year                        Third Year
                                                                      -0-

              Project 23   Heart Sounds Screening of School Children
                                                                   Requested
                                                                   First Year
                                                                   '$72,986
              This project ranked 20th, has been ongoing  for two years, with a
              commitment of $48,000 for the third year.  The request also includes
              support for an additional year beyond the approved current three-year
              period.
              This project is part of the Pediatric component of the NCRMP heart disease
              program.
              This is a program undertaken by the North Carolina  Heart  Assocation  in
              cooperation with Bowman Gray School  of  Medicine,  Charlotte-Mecklenburg
              County Heart Assocation, Mecklenburg County Health Department, Blue
              Ridge Health Council and the N. C. State Board of Health.  Using the
              Phono-Cardio Stan (18 pound computer) trained volunteer teams will
              attempt a pilot screening of 26,400 children, including  a  large  number
                 urban poor a
              of             nd rural  non whites. Upon completion of  the  study,  the





                                               -13-                 RM 00006 5/71
              NOIITH CAROLINA RMP
              results are to be analyzed and guidelines developed for tegion-wide
              screening.  The program includes advanced diagnostical and treatment
              follow up procedures.
              During the first 17 months, 9728 children were screened.  Of those
              screened, 924 required further examination by a physician - 872 were
              actually followed.  Of the 872 followed' 323 had histories of previous
              heart disease and 549 were asymptomatic.  The application includes
              detailed data about the follow up results.  The project has involved
              3780 hours of 239 volunteers and 57 physician hours.
                               Second Year                        Third Year
                                $27,070                               -0.





                                           -14-                        RM 00006  5/71
          North Carolina RMP


          RENEWAL PROJECTS                                           Requested
          Project #lR   Education and Research in Community          First Year
                                                                      $216,798
                        Medical Care

          Founded in 1965 by the University of N.C. Medical School, the   lp   roject
          began receiving support from the NCRNP to expand its activities aimed at
          cooperative Arrangements among hospitals and.medical centers.  Its purpose
          was to promote area-wide planning, health-rolated transportation and
          continued education including the TV  media.  The  project,  ranked  13th,
          has been suvrorted by RMP for three years at an  average  annual  level  of
          s2i,4,oon d.c.o. Three additional years of  support  are  now  requested.
          The oripinal reviewers an(] 1967 site visitors observed  that  the  project
          had an unclear focus with many different activities.  However, most
          reviewers believed that the program was reaching out into areas Away from
          the medical centers.
          P@oject efforts have  contributed to the establishment of A comprehensive
          care system in one north central county and its inclusion in an OEO funded
          community health care project. The  air  transportation  system  has  made
          it possible for specialty physicians to conduct bi-weekly otolaryhgology
          clinics in two small communities (Morganton & Tarbors).  Four of ten
          non-university hospitals with 300 beds or over now have university
          affiliations.  During the past year,  24  one-hour  professional  education
          programs were aired through five University  transmitters  with  the
          potentiality of reaching 787. of the states physicians.  -The  air  system
          has provided transportation for  pediatric  specialists  with  residents,
          once a week, from the University of N.C. to a  hospital  in  another  small
          community (Wilmington).  The aircraft also transport  11 :vhvsicians   from
          Wilmington to the UNC Medical School for profci-siibn'al learning.
               Second Year                                         Third  Year
                $231,388                                            $256,028

                                                                     Requested
          Project #4R - Central Cancer Registry                      First Year
                                                                       $25,975
          Ranked 12th, this project has been supported by RMP for
          three years at an average annual I.evel  of  $101,104.  Three  additional
          years of funding are requested.
          The purpose has been the development of a  central  reference  to  collect
          comparable data with computer storage and retrieval capability.  The
          prime purpose was to provide for practicing physicians with an educational
          tool in patient management. Of secondary  importance  the  data  would  be
          available to investigators and planners.





             'North Carolina RMP               -15-                        RM 00006  5/71


                      nge, problems  arose  in  system  incompatibility  with  equipment
                                  f Health, which necessitated re-design of the form.
                      ate  Board  o
             D4q                  eriod information was received from the 10 pilot
               ,  M,@he  interim  p
             hospitals, and their registry  secretaries  were  given  instruction  at  a
             four-4ay workshop.  Nine additional hospitals have since been added and
             their secretaries  trained.  Transition  of  the  mechanical  operation  to
             the State is in progress.  A special committee has been formed to give
             guidance to the activity and to be the liaison between the data gat ers
             and physician consumers.

             The State Board of Health is seeking funding of the project services
             from the State Legislature.

                Second Year                                             Third   Year
                  $299829                                                $31,429

                                                                           Requested
             Project #7R - Continuing Education in Internal Medicine  First Year
                                                                             $11,075
             Ranked 25th, this project has been supported for three
             years at an average annual level of $25,028.  Three additional years of
             finding are requested.

             The main objective of this activity  has  been  to  improve  patient  care,
             improving the relationship between practicing internists and the University,
             and to improve skills and knowledge.  This was to be accomplished by
             giving the practicing internists an opportunity to train for two to four
             weeks in the Department of Medicine of one of the three medical schools,
             The project seems principally the same except, it now includes general
             practitioners.  Number trained:  let year, 8 physicians from 8 communities
             (6 for 4 weeks and 2 for 2 weeks);  2nd  year,  17  physicians  for  11
             communities (1 for 4 weeks and 16 for 2 weeks).  Post training interv ews
             are planned of those trained during the first three years to determine if
             the trainees believe the experience has contributed to improving the quality
             of their service.

                Second Year                                             Third   Year
                  $11,075                                                  $11,075

                                                                           Requested
             Project #8R - Continuing Education in Dentistry               First Year
                                                                             $69,925
             Ranked 8th, this project  was  supported  for  three  years  at
             an average annual level of $65,086.  Three additional years of funding
             are now requested.




                                                                           RM 00006  5/71
                                                 -16-
               North Carolina PM


                                                                              ny patients
               The overall objective of  the project is to insure that as mm
               as possible receive appropriate dental care as part of their comprehensive
                     .The project is also 'striving to expand,and  improve  the  role  of  the
               care,
               dental profession in patient  care  in  the  community  hospital.  Course*  are
                         for dentists to acquaint  them  with:  1)  current  information  on
               @the diagnoses, management and follow up of patients with categorical
               diseases; 2) hospital  practices;  and  3).maxillofscial  reconstruction..
               'Courses are Also offered to physician and dentists dealing with cooperative
               patient care,
               During the current  project  period  Accompl.ishments   include.developmen   of
               .programs,, concurrent with selecting training sites.  Six of thirty hospitals
               were selected in different  areas.  Coordinators  recruited  for  each  area,
               were involved in planning. @Programs in  seven  of  eight  subjects  have  been
               completed And delivered to the six hospitals.  Attendance in small communities
               is reported to be good.  Evaluation by   objective  testin  his  not  been
                                                                           9
               successful.
                  Second Year                                             Third Year
                    $58,051                                                $609283
                                                                            Requested
               Project #9R    ContinuinR    Education for Physical          First Year@
                                                                             $67 182
                              Therapists

                 n           this proje              sup
               Ra ked 19th              ct  has  been   ported.for three  years'at an
               average annual level of $27,254.
               .This project continues to address   the problem of inadequate number of
               PTs in the State and inequities in their geographical distribution.  These
               problems are reported as increasing due to increasing numbers of extended
               care.facilities, nursing homes and home care agencies'.
               The project plant to continue to strengthen local continuing education
               programs; provide consultation; intent   ify efforts  to  provide  in-service
               education; explore ways and means of  relieving  solo  PTs  to  provide  them
               with opportunities for continuing education,an4/or vacations; and provide
               consultation  to  administrators  considering  offering  physical  therapy
               services.
               Progress:  1) an.evoluation method has been devised to assess patients who
               have,had cerebrovascular accidents, can be  used  as  a  basis  for  planning
                           and for training; 2) a professional education movie on "Xrestmeiit
               of Clubfoot" was produced; 3)  155  programs  were  conducted  in  9  different
               areas for 530 appropriate allied health personnel (155 PTs).
                   Second Year                                             Third Year
                     $ 4,678                                                $68,568




              North Carolina RMP               -17-
                                                                      RM  00066   5/71

                                                                         Requested
              Project #13R - Cardiopulmonary Resuscitation               First Year
  10    I                                                                  $62,388
              Ranked 10th, this project has received RNP support for
              three years at an average annual  level  of  $64,689.  Three additional
              years of funding are now requested.

              This project has sought to make the CPR technique  known  and  available
              throughout the state. The project previously  reported  that  a  regional
              training facility had been established at the Charlotte Memorial Hospital
              and the CPR Committees were established in  5 communities.

              During the first triennium, 62 CPR Committees have  been  established  and
              57 are now.engaged in training.  Those  trained:  292  physicians,  1,975
              nurses, 45 dentists, 1,490 hospital personnel, 72 a mbolance   personnel
              241 rescue squad personnel, and 33 others  hospital  related.  During  a
              15-ammth period, 29 hospitals performed 161  resuscitation  attt  to,  88
                                                                              MP
              patients responded, 53 were discharged alive.

                 Second Year                                          Third   Year
                   $61,896                                              $56,041

                                                                         Requested
              Project I#14R  Heart Consultation & Education Program      First Year
                                                                            $7,050
              Ranked 18th, this project has been supported.for three years
              at an average annual level of $8,721.  Renewal for one more year is re4ueott

              This project has represented an arrangemen t between Bowman Gray and Memorial
              Mission Hospital in Ashville to provide a training base for  the  CCUs  in
              small hospitals in the State of Franklin area.

              It is proposed that this continuing education activity  be  continued  at
              the sub-regional medical tenter serving the western part  of  the  state.
              Since this project began, 460 physicians and 92 nurses  have  attended  22
              program sessions at Memorial Mission Hospital.  An evaluation questionnaire
              from 44 physicians indicated favorable results.

                 Second Year                                          Third   Year
                   -0-                                                     -0-

                                                                         Requested
              Project #1.5R - 'C"prehensive Stroke Program               First Year
                                                                           $207,000
              Ranked 7th, this project has receive RHP support for three
              years at an average annual level of $194,682.  Three more years of funding
              are now requested.

              The purpose of this project has been the  development  of  comprehensive
              stroke programs through a central coordinating unit at Bowman Gray School
              of Medicine. This program was developed with  assistance  from  the  North
              Carolina Heart Association. The NCRMP Stroke  Committee  serves  as  the






                                                                      RM 00006 5/71
            North Carolina RNP                -18-

            Advisory Group for the activity.   The initial projectrS a ti-4itie
                                                                       c       S.
            1) publication of guidelines for  community programs; 2) education programs
            for nurses; 3) annual workshops;  and 4) development of a family patient
            education  unit.
            In addition to the overall objective to offer stroke patients increased
            pportunities for early diagnosis  and  treatment,  early  hospital  discharge
            0
            and continued follow up; the project is to be broadened to include primary
            prevention   Screening clinics will concentrate on.target populations,
            e.g.,-children of stroke victims and individuals with personal or family
            histories of,risk factors.  The project will also consolidate the gains of
            programs and continue to in.crease.their independence from  RMP  support  and
            establish new programs emphasizing training an4 utilization of existing
            manpower.
            Since the project began, more.than 1,000 existing personnel have been
            trained and coordinated to provide quality units  and  follow-up  care  among
            915,000 people in 19 counties.  Data gathered of 122 pre-stroke program
            and 145 post-program patients indicate the activities to be effective.
               Second   Year                                         Third Year
                $212,129                                              $219,184

            PR(XJECTS SUPPORTED DURING THE FIRST TRIENNIUM FOR WHICH CONTINUING SUPPORT
            IS NOT REQUESTED BY NCRMP:
            Project #ln  - Coronary Care Units in Small Hospitals  (State of Franklin
                           supported 3 years) will sustain its own continuation without
                           further RMP support except for continued use of grant
                           equipment  property.
            Project #11  - Mobile Cardiac Intensive Care - Haywood County Hospital
                           supported 1 year
            Project #12  - R6gional Coronarv Care Unit for Physician and Nurse Education
                           Bowman Gray - supported 1 year
            Project #20  - Mammography Technologists Traini    Program - supported I year
            Project #24  - Medical Student Operation of Edgemont Clinic - approved for
                           three years - supported partially for  one  year  from  carry-
                           over funds
            Project #25    Problem-Focaued, Group-Oriented and Community-Based
                           Continuing Education    approved for 3 years, but not funded





                                                                            RM 00006  5/71
                                                -19-
             'North Carolina RNP


                PRO.JECTS PREVIOUSLY
                                                                          Requested
                Project #26 - Emphysema and Lung Disease                  First Year
                                                                            $123,905
                The July 1970 Council agreed with the Review committee
                that the need, objectives and procedures seemed clear, but there was some
                question about the justification for equipment budgeted for six hospitals.
                There was also some question as to the ability of the physicians in the
                satellite hospitals to operate effective respiratory care units.
                Ranked ith, the overall objective of this project is to make it possible
                for all North Carolinians to acquire within 50 miles of tbei  r residence
                up-to date diagnosis and treatment for coronary disease.  Specific objectives:
                1) development of a regional pulmonary care training center at Duke University
                Medical center; 2) improvement of diagnosis and treatment capabilities at
                six hospitals; 3) establishment of formal communication linkages among
                participating institutions to provide continuous respiratory services,
                improve referral resources and increase the index of community awareness.
                of respiratory disorders And required services.
                  Second Year                                            Third Year
                   $27,670                                                $28,478


                NEW PROLJECTS
                                                                            Requested
                Project #27 - Dial Access                                   F rat Year
                                                                              95,846
                Ranked 4th, this project addresses the need for quick
                access of current health knowledge to health personnel.     The informational
                center will consist of staff, equipment and brief tapes.  Toll-free access
                will be Accomplished through a series of (WATS) telephone lines connected
                to the resource (24-hour service).  Future considerations include consultation
                and drug reaction information.
                  Second Year                                             Third Tear
                     $94,461@                                               94,178
                                                                            Requested
                Project #28 - Care--            with Chronic Uremia         Fir
                              in            line                             $486,550
                This project is to be reviewed with all other kidney proposals by the
                RMPS Ado""Hoc Kidney Disease Panel prior to the May Council meeting.
                According to the letter covering the present application, this project
                was approved by the NCRMP RAG with the stipulation that it be reviewed
                in competition for RMPS funds earmarked for Kidney Diseases.




               North Carolina RNP                -20-                   RM 00006  5/71

                                                     total approach to the treatment of
               This projects ranked 16th, proposes a
               chronic uremia in North Carolina.  Approximately 300 new patients per year
               in the state are acceptable for dialysis or transplant.  Less  than  1M.
                                                               Specifically, the project
               are presently receiving appropriate treatment.
               ,proposes capability for dialysis and transplantation by activation of
               connunity-dislysis and treatment centers  establishing a state-,wide system
               of histo-compatibility testing,and continuation of a N.C. organ procurement
               program.
               The objectives.include creation of a system to attain fundi ng from  all
               sources, and to evolve training for physicians. and other -appropriate
               allied health personnel.
                  Second Year                                          Third Year
                    $395,166                                            $398,473
                                                                         Requested
               Project #29 - Continuing Education for Physicians and     First Year.
                             Allied Health Personnel in Eastern N C       $102,086
               Ranked Ilth, the main objective of this project is to provide for participating
               hospitals, continuing education programs to upgrade the knowledge and skills
               of physicians and allied health personnel.  Another objective is to identify
               and assist entraining personnel to serve as educators in the programs to
               be developed.  A third objective is to help community hospitals create a
               professional climate conducive to recruiting and retaining qua lity health
               care professionals.
                  Second Year                                          Third Year
                   $130,300                                             $144,200
                                                                         Requested
               Project #30 - Rheumatic Fever Program                     First Year
                                                                          $112,805
               Ranked 6th, this project has been designed by the State
               Board of Health and the North  Carolina  HeartlAssociation.  The  target
               groups are children with a beta hemolytic  streptococcal  infection  and
               those having hod  rheumatic fever.  A secondary.prevention program will
               combine existing programs,, and expand a unified health-care approach to
               ensure continued prophylaxis    through use of a registry.  A primary
               prevention feasibility study will be conducted in two counties and
               supplementary investigation in the remainder of the state.  The questions
               to be answered include, what exactly is feasible in such a program and
               what would the costs be.  A study will also determine the feasibility of
               a free.,prophylactic  drug program.
                  Second Year                                          Third Year
                  @107,436                                               $110,876



                 North Carolina R14P             -21-                       Ri4 oooob  5/71
                                                                            Requested
                 Project #31 - Comprehensive Cardiac Pacemaker              First Year
                              Education Information Program                   $27,476
                                            1 is that all pacemaker patients will receive
                 Ranked 2nd, the project goa            are 1,000 per ons in  the  state  with
                 the best management.  Currently there                11
                 implanted pacemakers and th6 number is expected to  rise  to  3,OW  by  1974.
                 By the end of the third year, the project  anticipates:  1)  that  an  evalu-
                      program for monagment of all  such  patients  will  have  been  established-
                 ation                                                                           0
                 2) all such patients registered will have been provided with basic information
                 including how to obtain immediate medical care anywhere in the State;
                 3) a 24-hour information and advice service for physicians; 4) all physicians
                 with pacemaker patients will have received the latest information on pace-
                 maker apparatus and management; and 5) the Advisory Committee to the project
                 will have completed and submitted a thorough evaluation of the project.
                   Second Year                                             Third Year
                     $20,996                                                $21,236
                                                                              Requested
                 Project #32 - A Model Program for Career-Ladder              First Year
                               Nursing Education Program                      $91,919
                 Ranked let, this project addresses  the  health  care  needs in the low socio-
                 economic Albermarle area and the  needs  for  more  adequate nu-roing'services
                 there.
                 The project objectives include establishing tests for selection and advanced
                 placement of licensed practical nurses interested in upgrading their skills;
                 use of advanced placement as an incentive  for  motivating  capable  LPNB  to
                 continue their formal. training, improve the two-ytar associate degree
                 program in nursing At the  College  of  Albermarle.  Objectives  at  the  College
                 include:  1) provide an innovative curriculum to upgrade LPNE; 2) train
                 more LPNs to bridge the gap of RN shortage; and 3) continuously revise
                 the curriculum on the basis of evaluative feedback.
                    Second Year                                             Third Year
                       97,487                                               -T84,237
                                                                              Requested
                 Project #33 - Regional Continuing Education for              First Year
                                Nursing Cate                                  -@24,017
                 Rated 17th, the project goal  is  to  improve  patient  care delivery by increas ng
                 the knowledge and skil.19 of nurses, both employed and inactive.  This wil
                 be accomplished through implementing continuing education for nurses through
                 18-30 colleges and/or technical institutes (6 the Ist year And 6-10 in the
                 2nd and 3rd years).
                    Second Year                                             Third Year
                      $34,137                                                 $36,400





                     o I. ins RMP           -22-                            RM 00006   5171
            North Car
                                                                       Requested
                                           @titioner                   First Year
            Project #34   Family  Nurse  Prg                                 ---
                                                                         $1929575
            The covering letter to the present application stated that
              artial support for this activity may be possible through the Health
            p
            Services and Research Center at the University of   N.C.
            Ranked 18th, this  project  addresses  the  physician'shortage  particularly
            in rural-areas.'  It proposes to develop a training program to prepare
            family nurse  practitioners  who will return to serve their local communities.
            They will be trained to provide primary care to individuals and families
            in health centers, clinics, physician's offices, industries, homes and
            other ambulatory care settings. Ten will be  trained  the  let  year,  four  een
            the second year and eighteen the  third  year.  They  will  receive  initial
            training for 5-6 months and then return  to  their  communities  for  experience
            in their,local employment settings  returning  periodically  to  the  Chapel
            Hill for further training and  clinical  experience.  During  the  latter  phase
            physicians from their local communities will also go   'to Chapel  Hill  for
            orientation with the nurses so they may  function  more  successfully  as  a
            health team.

                Second Year                                            Third Year
                 $209,400                                               $232,189
                                                                         Requested
            .Project #35 - Adult Screening and Referral   for Hyper-     First Year
                            tension, Heart Disease, Stroke, Diabetes      $121,474,
                            and Anemia
              Ranked 22hd, the project objectives are to field test the screening program
              using 200,000 adults.  After evaluation of field tests and necessary
              modifications, the program will be extended to the entire state.  Tests
              are:  electrdcardiometer, blbod pressure, blood glucose, hemoglobin, and
              I%rotid Bruit.  A system of referral and follow up is to be included.
              Evaluation methods-are described.
                Second Year                                            Third Year
                  $96,71.1                                               $99,024
                                                                          Requested
              Project #36 - Canc      0  ram                              First Year
                                                                            262,694
              Ranked 3rd, this project  proposes to: 1) develop a  full  array  of  services
              to cancer patients by building on current resources; 2) promote regions-
              lization of@cancer services by developing linkages between community
              hospitals and clinics, regional  hospitals  and  university  medical  centers;
              3) augment continuing education services for professionals and laymen;
              and 4) coordinate existing cancer control resources and encourage improved



             North Carolina RMP                   -23-                      RM 00006  5/71

               utilization and effectiveness. In addition  to  relating  to  other.cancer
                      a in this application, the project will address itself to the need
               project
               for a regional radiation therapy-center, nuclear medicine training, study
               of  patIient and.family perceptions, genitourninary  maligancy  control  and
               radiation therapy.planning services.
                  e ond     r                                           Third Year
                     03,095                                              $209,765



                                                                          Requested
               Project #37    Cooperative Program in Continuing           First Year
                              Education                                     $69,,699
               Ranked 5th, the project proposes approaching the need    for improving patient
               care through two prime goals:  1) to provide each physician in the state
               an opportunity for continued education with his own State Medical Society
               district; and 2)-involve the active cooperation of  the  three  medical  schools
               and the State Medical Society in the project.  Emphasis  will  be  on  providing
               programs to meet the needs  of  physicians.  Programs:  nine  half-day  sessions
               within easy  traIvel distance; 1 half-day program at each  of  the  three  medical
               schools; and one annual symposium.
                  Second   Year                                         Third Year
                   $79,975                                                98,100
                                                                          Requested
               Project #38    Cancer Telephone conference                 First Year
                                                                            $26,900

               Ranked 26th, this project is to  establish  telephone  cancer  conferences
               for physicians between the universities and the 3 regional    centers.  Each
               center will: 1) select cases; 2)  prepare  and  mail  appropriate  x-rays,
               slides and other references to the consulting university and schedule
               conference attendance.
               The consulting University will:  1) review case material; 2) respond to
                        participants during the conference following the came presentations.
               One-hour conferences will consist of two case presentations.
                  Second   Year                                          Third Year
                     $27,670                                              $28,478




                                                                                GRB/3/23/71










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          North Carolina RMP                        -25-                    RM 00006  5/71






             TABLE II By PROJECT ORDER

             Rating  Ranking  Pro_iect No.                        Project
             4.16       13.        IR           Education & Research in Community Medical Care
             2.53       4.         2R           Coronary Care Training & Development
                                   3R           Diabetic Consultation
             4.14       12.        4R           Central Cancer Registry Utilization Program
                                   5R           Medical Library
             6.26       25.        7R           Continuing Education in Internal Medicine
             3.58       8.         8R           Continuing Education in   Dentistry
             5  03      19.        9R           Continuing Education for Physical Therapists
             3.96       10.        13R          Closed-Chest Cardiopulmonary Resuscitation Program
             5.18       21.        14R          Heart Consultation & Education Program
             3.48       7.         15R          Comprehensive Stroke Program
             4.28       15.        17R          Regional Center for Trophoblastic Diseases
             4.22       14.        18           North Carolina Tumor Tissue     g stry
                                   19           Physician Assistants
             5.62       23.        92           Coordinated Oncology Chemotherapy
             5@@l@Ow    20.        23           Heart Sounds Screening
             6.00       24.        27           Dial Access System.
             4.39       16.        28           Care of Patients with Chronic Uremia in North
                                                Carolina
             4.03       11.        29           Continuing Education for Physicians & Allied
                                                Health Personnel in Eastern North Carolina
             @3.2@6@    6.         30           Comprehensive Rheumatic Fever Prevention  rogram
             2.37       2.         31           Cardiac Pacemaker Education & Information Program
             2.13       1.         32           A Model Program for Career-Ladder Nursing
                                                Education
             4.49       17.        33           Regional Continuing Education for Nursing Care
             4.92       18.        34           Family Nurse Practitioner
             5.24       22.        35           Adult Screening and Referral Program for Signs
                                                of Hypertension, Heart Disease, Impending Stroke,
                                                Diabetes & Anemia  .
             2.47       3.         36           Comprehensive Cancer Program
             3.04       5.         37           A Cooperative Program of Continuing Education in
                                                Heart Disease, Stroke and Cancer
             3.95       9.         26           Emphysema and Lung Disease Program
             6.41       26.        38           University Regional Telephone Cancer Conference



               Not   ranked







                                                                            RM  00006   5/71.
                                               -26-
       North Carolina RMP
                              PROJECT 11 RATINGS AND RANKING BY NCRMP ADVISORY COUNCIL

                                           DECEMBER 16, 1970


            TABLE  I  By  RANK  ORDER

                                                              Project
            Rating   Ranking   Proiect No.
            2.13       1.           32         A Model Program for Career-Ladder    Nursing
                                               Education
            2.37       2.           31-        Cardiac Pacemaker Education &   Information Program
            2.47       3.                      Comprehensive Canter Program
            2.53       4.           2R         Coronary Care Training & Development
            3.04                    37        'A Cooperative Program of Continuing Education in
                                               Heart Disease, Stroke and Cancer
            3.26       6.           30         Comprehensive Rheumatic Fever Prevention Program
            3.48       7.           15R        Comprehensive Stroke Program
            3.58       8.           .8R.       Continuing Edutation in Dentistry
            3.95       9.           26         Emphysema and Lung Disease Program
            3  96      10.          13R        Closed-Chest Cardiopulmonary Resuscitation Program
                                    29         Continuing Education for Physicians & Allied
            4,03       11'
                                               Health Personnel   in Eastern North Carolina
            4.14       12.          4R         Central Cancer Registry Utilization Program
            4.16       13.,         IR         Education & Research in Community Medical-Care
            4.22       14.          18         North Carolina Tumor Tissue Registry
            4.28       15.          17R        Regional Center for Trophoblastic Diseases
            4.39       16.          28         Care of Patients with Chronic    Uremia in North
                                               Carolina
            4.49       17.          33         Regional Continuing Education    for   Nursing Care
            4.92       18.          34         Family Nurse Practitioner
            5.03       19.          9R         Continuing Education for Physical Therapists
            5.10       20.          23         Heart Sounds Screening
            5.18       21.          14R        Heart Consultation & Education Program
            5.24       22.          35         Adult Screening and Referral Program for Signs
                                               of  Hypertension,  Heart  Disease,   Impending
                                               Stroke, Diabetes & Anemia
            5.62       23.          22         Coordinated Oncology Chemotherapy
            6.00       24.          27         Dial Access System
            6.26       25.          7R         Continuing  Education  in  Internal   Medicine
            6.41       26.          38         University Regional Telephone Cancer Conference
                                    3R         Diabetic Consultation
                                    5R         Medical Library
                                    19         Physitian Assistants


                Not ranked




                                                              A Privileged Communication.
                                         -27-                  Rm 00006



                                        SITE VISIT REPORT
                             NORTH CAROLINA REGIONAL MEDICAL PROGRAM
                                      November 17-18, 1970



               ,rd4pS Visitors


               Council
               Blond W. Cannon, M.D., Memphis Tennessee


               Review Committee
               Henry Lemon, M.D., Professor of Medicine, University of Nebraska, Omaha,
                 Nebraska


               Consultant
               Edward D. Coppola, M.D., Associate Professor, Department of Surgery,
                 Hahoemenn Medical College, Philadelphia, Penneylvaniia


               Staff
               Dan Spain, Public Health Advisor, Regional Development Branch
               Luther J. Says, Jri, Public Health Advisor, Grants Review Branch
               Theods H. Griffith, Public ReAlth Advisor, HEW Region IV


               North Caroling Regional Medical Program

               RAG & Board of Directors
               George W. Paschal, Jr., M.D. Chairman, Advisory Council, Association (RAG)
                 for the NCRMP
               Joseph Gordon, M.D., Vice Chairman, RAG, (Kato B. Reynolds Memorial Hospital,
                 Winston Salem, N.C.)
               William B. Henderson, Chairman of Board of Directors (N.C. Medical Care
                 Commission)
               Robert Smith, M.D., Vice Chairman of Board of Directors (Division of
                 Education & Research in Community Health, University of North Carolina),
                 Project #1 Education and Research in Community Medical Care
               William G. Anlyan, M.D., Board of Directors (Vice President, Health Affairs,
                 Duke University School of Medicine
               Manson Meads, M.D., Board of Directors (Dean of Bowman Gray School of
                 Medicine, Wake Forest University)
               ,W. Fred Mayte, M.D., Board of Directors (Dean of University of North Caroling,
                 School of Public Health)
               Isaac M. Taylor, M.D., Board (Dean, UNC School of Medicine)
               Louis de Si Shaffner, 14.D., Board of Directors (President, Medical Society
                 of N.C. and Professor of Surgery at Bowman Gray School of Medicine)
               William F. Andrews, Board (Administrator, Memorial Hospital of Wake County)@l,
               Motion Poster, Board (Executive Directoro N.C. Hospital Association)
               Jacob Koomen, M.D.. Board (Director, N.C. State Board of Health)
               E. C. Miller, M.D., Board (Associate Dean for Continuing Education, Bowman
                 Gray School of Medicine)





           North Carolina RMP                  .28-                               RM  00006


           Staff
           F. M. Simmons Patterson, M.D'   Executive Directot
           Be'n Weaver, Deputy Executive.;irector
           Audrey Booth,   R.N.   Director,   Division of   Professional    Services
           Lee Holder, Ph.D., Director, Division     of Planning and Development
           Ron Davis, Ed.D., Director, Division     of Continuing,Education
           Manley Fishel, Assistant Director,,Proj@ct Development
           William W. Lowrence, Director, Division,-Hobpitals       and  Institutions
             Services
           Jo  Ann Olsen, Health Records Administration
           Robert Whitfield, Director, Fiscal Services
           John Young, Assistant Director, Project Development
           Susan West, Assistant Director, Communications
           Harvey L. Smith, Ph.D., Director, Division of Research and Evaluation
           Virginia Benton, Director, Division of Communication
           Robert Headley, M.D. , Director, 'Hi!ar't' Disease Program (Bowman Gray school
             of Medicine) Project #2 Coronary Care Training and       Development
           William De Maria, M.D., Consultant, Continuing Education (Duke University)
           E. Harvey Estes, Jr., M.D.  Coordinator for Duke University (Past Chair-.
             man of the NCRMP Board of    Directors)
           Makine  Stern,  Division  of  Research  and Evaluation -.(UNC)
           St:snnon  P.  Hallman,  Division of Research and Evaluation


           Projxrom
           @ye   H. Kilbu'i:ri-, M.D. Project  #26  -  Emphysema  and  'Lung  Diseas.e   (Du.ke
             University)
           Reginald Harris, M.D., Project #26 (private  hysician, Shelby)
                                                            p
           Samuel McMahon, M.D., Project #26 (Duke Univerait
                                                                  y
           G. M. H lprin, M.D., Project #26 (Duke University)
              W. W:tts, M.D.  NCRMP Cancer Committee ('Lincoln      Hospital)
           James  McFarland,  M.D.,  Director,  Project  #2  Coronary  Care  Training   and
             Development and Project #13 CPR
           Donald Hayes, M.D., Cancer Committee, Assistant Director, Project #22
             Coordinated  Oncology  Chemotherapy  (Bowman  Gray   School   of   Medicine)
           Charles Sp@rr,.M.D        rect  r,  Project  #22  Chemotherapy  (Bowman   Gray
                                          Q
             School  of   Medicine)
           Roscoe  Robinson,  M.D.,  Renal  Disease   Program
           Marjory  Johnson,  Project   #9   Continuing.Education   for.Graduate   Physical
           '-tfier"Spie'to' (Assists-nt   Profe aso.r,   Universit y of N.C.)
           Susanne L.  Chase,  Project  i@2'1'lnnovations  in  Clinic  Nursing  (School  of
             Nursing, University of N.C.)
           Don L. Marbry, D.D.S., Director, Project #8 Continuing Education in
             Dentistry  (Ul4C,  School  of  Dentistry)
           Robert  Howard,  M.D.,  Project  #19  Training  Physician's   Assistants   (Duke
            .University   Medical   Center)
           Charles  Hammond,  M.D.,  Assistant  Director,   Project   #17   Trophoblastic
             Cancer (Duke University Hospital)
           John Payne, M.P.H., Project #1 Education and Research in Community Medical
             Care  (UNC,  Health   Sciences)
           B. Lionel Truscott, M.D., Director, Project #15 Stroke (Bowman Gray School
             of Medicine)





                North Carolina RMP              -29-                          RM 00006


                Other
                Betty Compton, Student, UNC, School of Nursing
                Evelyn Aabel, Student, UNC, School of Nursing
                Arthur E. Wentz, M.D., Coordinator, Metropolitan Washington, D.C. - RMP
                Joseph Costello, Biostatintician, West Virginia RMP
                William Warlick, South Carolina RMP
                Jack Mason, Ph.D., Virginia RMP
                Robert A. Youngerman, InterRegional Representative for the S.E. RMP's
                L. J. Heaphy, Jr., M.D., Cooperative Activities, Bowman Gray.School of
                  Medicine
                Kathryn Taylor, Memphis RMP
                Russ Cla.ck, Memphis RHP
                E. W. Miller, Memphis RMP
                Bob Randolph, Health Planning Consultant, Charlotte, N.C.
                Lewis N. Amis, Memphis RMP
                Ellen P. McDowell, Memphis RMP
                H. M. Filts, N.C. Central University
                Hugh A'-Mathews, M.D., President, State of Franklin Health Council
                Charles W. Edwards, Jr., State of Franklin Health Council, Mountain
                  Romparts, Inc.






                                                                           RM 00006
         North Carolina RMP

                                                                          e of the
                                                          conducted becaus
         PURPOSE OF  THE  S     SIT4  This site visit 'Ws a                     iew
                          ITE V'S'T'
                                      anticipated - the initial anniversary  rev
                     pli@tion   - to be submitted by February 1. 1971.  The' NCRNP
         triennium  Ap
         is  currently in its third operational year with a funding level  of $2,047,486 d.c.0
         for core staff and  22 projects.  the IQCRMP. va is last site visited November 1967.
         The site visit team  considered the  following aspects of the NCRNP:
               1.  Historical Development

               2.  Exciting Resources
               3.  Major Perceived Problems in Health Care
               4   Analysis:of Program Characteristics

                   S.  Coal,a

                    b.  Organization
                     C. Cooperative Arrangements
                     d. Planning Functions'

                     e.. Evaluation Functions

                     f. Achievements
                5.  Future Funding Recommendations
            SUKMARY:  North Carolina was one of the earliest regions to recognize its
                     opportunity for improved health care delivery, and to begin active
            planning of its program.  The Deans of all 3 medical.schools in the state
            had been simultaneously replaced in 1965 before the Heart, Cancer, Stroke
            enabling  legisIlotion was debated and passed, and from the inception of the
            planning, they worked closely together, as a team of leaders, alon  with
                                                                               9
            the Dean of the University of North Carolina School of Public Health.  This
            academic leadership was able to sell the concept of the program to the
            leadership of the State Medical Society, although many of the county
            societies were, disinterested in developing the Advisory Council of Health
            Professions (later Board of Directors).  Dr. George Paschal and the 4
            deans worked closely together with Dr. Jacob Koomen, head of the Department
            of Public Health, and other key figures from the Medical Care Commission,
            who functioned as the Board of Directors of the program and who employed
            Dr. Marc Musser as first director.   From the time of its selection, the
            Regional Advisory Group (or Council) was limited to an advisory position
            with limited activity and no real power except as its membership included
            some of the Board of Directors.   The present program represents chiefly





                North Carol ins RMP              -31-                            RM 00006


                the planning and evaluative activities of the Deans and the other members
                of the Board of Directors, with momentum developed by the very active
                recruiting and organizing activities of Dr. Musser.
                In April 1970, Dr. Simmons Patterson assumed the directorship of the program,
                                   gthened the  'flif--components of the core staff operations-.
                and has since stren            fu    me
                he brings to the job experience as a long-time practicing surgeon in eastern
                North Carolina, 8 medically remote section, and some earlier work with
                cancer planning for the area as a member of the core staff.  Thus the
                preponderant academic make-up of the Board-of Directors has now been
                belabced by an experienced surgeon with broad professional experience and
                acquaintance.
                Dr. Patterson has strengthened thf! planning and administrative functions
                of the core staff, and has demonstrated a sol.id ability to continue
                Dr. Munser's leadership with an improved organizational approach, needed
                after the rapid development of many new programs.


                Resources

                The resources of the regiotl, for its RMP act*vity are outstanding, especially.
                     a) Three aggressively led medical schools with obvious interests in
                community health care, continuation education,.and innovative training
                activities.  Each has its patient flow area and various kinds of outreach
                programs.
                     b) An outstanding School of Public Health, which has developed area
                wide public health nurse activities and a  graduate  program  of  considerable
                size, annual budget $7,000,000.
                     c) An excellent and cooperative Department of Public Healt
                     d) Dedicated Medical Society and Hospital Association leadership
                many of the same figures were present now as 3 years ago - Dr. George
                Poscfial, Past President,of the North Carolina State Medical Association;
                Mr. Henderson, Chairman, Advisory Council, Chairman, Board of Directors
                NCRMP, Exec. Sec'y. of North Carolina Medical Care Commission; Dr. Jacob
                Koomen, Director, State Board of Health, etc.
                     e) Centrally located headquarters outside of the  Medical  Centers  in  a
                former Private home.
                     f) Rapprochement betwppn the white and non-whitf- communi.tips, or  shown
                t,y recent integration of hospital care facilities, State Medicol Association,
                and coonerativo assistance by RMP in OEO health  center  planning  In  Durham.

                        Private physician acceptance of npeds for trained mp(lical assistance
                in their pra..@ticvs, by 40-5M. of the 1,500 medical practitioners.







                                                                                Rm   00006
               North Carolina RMP                  -32-


               -                           d in Health  Care:
               1. Major Problems Recoltnize
                    1. one-half of all  hospitals  under  100 beds in size.
                    2.           ur'l population, isolated  into pockets by mountains   in
                       Largely-r  a
               the West. and by marshes and estuaries in the east.
                    3.  At least 177. non-white. with a predominance of low-incomp   white
               and non-white-citizens throughout  the  state.
                    4. Diminishing ratio  'of  Physicians  to population in rural   areas,
               with majority of those remaining  in  practice approaching retirment in
               in-15 years. State-wide ration 69 M.D./100,000;  90-95/100,I)OO  in  urban
               areas, 33/100,000 in rural areas, with 4M. over 60 years in  age.

               4.  Analvois of Program Characteristics:
               An attempt was made to numerically assess identifiable  components  of  the
               program (Table 1).  The discussion will amplify the table:

                    a) Goals:
                        'Those'selected were appropriate to the region's  heeds  and  have
               received modification with experience and changing Federal guidelines.  The
               were selected by a combination of data gathering,.intuitive and deductive
               input from medical schools, and local physician response to questionnaires
               and desires@  They appear to reach out to the entire state population,
               including the non-whites, and to those areas lacking professional coverage.

                    b) Organization:
                         .1. Program Director: Dr.  Simmons  Patterson  was  highly  rated
               by all the site visitors as a very knowledgeable, tactful, and able
               administrator, who works well with his Board of Directors, Advisory Council,
               and staff. 'He.views this job as a challenge based upon  real  needs,  and-
               is an understanding advocate of RMP, generating loyalty in his staff.
                         2. Regional Advisory  Group  (Council):  This  has  had  limited
               black representation, due to non-participation by several black candidates.
               it is not potent in decision making, but discussions are under way to
               increase its involvement in planning  and  in  decision  making.  Consumer,
               allied health, and lay  representation  is  deficient.  Procedures  appear
               standard, it is cooperative; and by some of its staff serving@on the
               Board of Directors or on advisory categorical committees, it does participate
               in the program.  Leadership has been stable and interested in the program.
                         1.  Bo rd of Directors:  This is the executive power structure of
               ,the program, harmonizing the actions of the 4 schools, the hospital associ-
               ation, and the Department of Public Health.  it  has  performed  very  ably
               to date, but its harmonious function could be disrupted or the direction
               of the program changed, by alteration in present- Dean composition (Dr. isas,
               Taylor to resigning as Dean at UNC  in  June).






                                                -33-                         RM 00006
               North Carolina RMP


                        4.  Core Staff:  Extremely competent with outstanding planning
               activity and excellent data gathering thus far.  Deputy director appears
               to have excellent administrative control.  Management and fiscal methods
               are those of Du ke University.  The Stroke director has outstanding ability
               in directing his program, and Heart director appears very good; full-time
               Cancer director is being recruited. 'Planning director, Dr. Lee Holder, also
               a capable evaluator, apoeara to be outstanding.
                        5.  Cooperative Arrangements:  Outstanding.  Nearly every possible
               public health agency has been drawn into the planning or operational program,
               with excepti on of the black medical association (less than 200 members out
               of 3,500 M.D.'s in state).  However, there has been active support given
               to the Durham GEO Health Center planning.  Arrangements do not appear to
               have been officially developed between Comprehensive Health Planning at
               the state level, but there in multiple and frequent involvement through
               Board of Director and Advisory Council member working on both 104P and CHP
               planning.  CHP definitely making use of RMP data base.
                        6.  Sub-regionalization of Activities:  Proceeding at different
               rates in varying locations, in various categorical areas.  Positive evidence
               of development of sub-regional@medical care activities in State of Franklin
               (west) in coronary care, in southern counties in cancer, and in all major
               sections of the state@in stroke.  Administrative sub-regionalization has
               not been developed.

                   c) Planniny,:
                        Very capable staff, in stroke and heart disease, and in allied
               health professionals.  Several members professionally qualified (Ph.D.,
               R.N., Ed.D.).  There is use being made of extensive medical manpower and
               facility data base which has been developed by the Evaluation section.
               Objectives are realistic, preliminary studies in some cases very imaginative,
               and existing resources are used cooperatively and extensively.  Priority
               selection has been reviewed at ].east once.
               Additional interaction between different categorical planning activities
               seems desirable.

                   d) Evaluation:
                        The evaluation section of the program to this point has consisted
               of a data-gathering activity for core planning, which has been productive
               of several monographs, forming a valuabl-e base for future activities.  The
               so-called evaluation branch is housed in one of the medical schools and is
               directed by an anthropologist who does not feel comfortable In an evaluation
               role.  Good evaluation proposals were not built into the emphysema project,
               indicative of a failure in project planning.  While the continued gathering
               of health care data will be desirable in the future and shoulti be retainer
               as a core activity, a stronger evaluation section must be developed in the
               core office, as a neutral site, to improve evaluation of progress, and to
               remove fears of institutional hiss, real or imagined.  The present deficiencies
               in evaluation activity seem largely offset by the superb job of data gathering
               performed to datti by Dr. HI' rvey Smith an(] his colleagues. which provides one
               of the beat possible platforms ffom which progress may be measured in the
                       -c --.- T)@ 4- t-ho entint-rv.







                                                                                  00006
                                                                             RM
            North Carolina RMP                 -34-


                e) Achievements:
                      Real progress has been made in the following areas-
                      1)IExpansion of coronary care units from 6 to 60 hospitals in
            the state4 establishment of self-supp oriing coronary pare units in the
            State of,;ranklin- where gross mortality has f6llen from 28% to 147. in a
            chain of rural hospitals.
                      (2) Establishment,of effective community hospital stroke rehabilit-
            ation progr gms in 113 of the 100 counties of the state - an outstanding
            accomplishment that might serve as a national model.
                      (3) An outreach cancer  chemotherapy program has  been  developed
            in about I /1 of the counties. in the went, involving 130 physicians, which has
            altered physicians' attitudes And behavior in caring for this  disease,  as
            has been the case in the stroke program.
                      (4) An extensive background for cooperative  medical  activity  has
            been developed between medical schools, the health department, hospital
            association, and the medical pro ess on.
                      (5) A.d,etailed Health data base has been collected and published,
            'has provided a-gtild6- o@r-'fii-M-i6 planning.
                      (6) Programs of physicians assistance  have been aided in  their,
            development.
                      (7) About 16 000 children have  be en screened for murmurs,  with
            3/1,000'suspecto found.
            Other projects in continuing education (cancer information service, central
            cancer registry, cardiopulmonary resuscitation,  continuing  education  for
            physic al therapists, Aental education, continuing education in internal
            @tiicine, education and research in community medical care, heart consultation
            and education, tumor tissue registry, trophobleatic center)  have  not  yet
            received evaluation by their proponents or by core staff.


            CONCLUSIONS:
            Overall rating   one of the best group of regions, upper 2M. category, based
                             upon present strengths:

                  (1) Program director,
                  (2) Core staff,
                  (3) Area   sources,
                  (4) Develypment of linkages and cooperation between institutions,
                  (5) Planning functions, especially in support of  rural  medical  care,
                  (6) Health data base for region,                                               -'@,
                                                                                                 ,@l;I
                  (7) Effective outreach programs in stroke, cancer,  and  heart  disease        ...I
                      and medical care assistance




                       North Carol ins RMP                               -35-                                            RM 06006


                       Chief weaknesses identified-.

                             (1) Regional Advisory Group,
                                   Dominant control  of program by Board of Directors representing
                                   medical schools - a strength in the past but potentially a
                                   weakness.
                             (3.)  Core evaluation input into planning.


                       RECO*MNDATIONS:
                       operational  funding for another 3 years at present or slightly (10%) higher
                       level.
                       Developmental component -  10% present direct costs  for 2 years, with renewal
                       contingent upon uses.
                       Oroiect #26 Emphysema:   The site visitors recommend two-year approval
                                                           for funding of two commun.it   hospital units outside
                                                                                                    y
                       of  Duke University,  for           personnel and travel.   No support for equipment
                       is  recommended.
                       Critique of@emphysema project:   Able direction, with good outreach into
                                                                       sub-regional emphysema screening and
                       consultation centers at local hospitals.   Training course  for nurses and
                       M.D  'a omits any reference  to smoking re-education of respiratory cripple.
                       fun@s  for Duke'# personnel  support not well justified,  since  they already
                       have a strong center - site visit committee believed  these monies would
                       be better used  for secretarial  or part-time physician assistance or
                        ohOultation   -                         hospitals.   N tevorthy involve
                       c                   in peripheral                            0                        ment by capable
                       interested internists at community hospital  level.

























                                                                                                                           ft I 'I '7 1 '7 1




                                                                              36
                                                                                                                                             Page 1-       of   2
                                                                         Region          North Carolina
                                                                                                                       Triennium
         Ist   Triennium (ct!rrent).                 funded                                    P .roposed 2nd           ][nd.     C.     .-
                                                     -  total                                                                                  T6tal       .02  .
                    'D.C.             Ind. c.
                                                                                                   3,815,-,178-        760-724              @4   63@19
                                                                                            04                               2                  9
            ol      1     572,201
                                                                                            05     3t591,384           7759729                   4,367,113
            02                                                                                                                                   4,321,835
                                                                                            06     3,559,498           762$337
            03      2,191,873
                                                                                                                                         GNENTS      BY      TYPE OF ACTIVITI
                                                                                                                                  coll".p
         CU@4PO\'ENTS BY        DISEASE  Ci.-c-GORY          tpr,;ent          03        YEAR
                                                                                                                           TRAINING         AND         EDUCATION
      ,,RT                                                                                                                        On-going
         On-goin                                                                                                                         Projects  17
            0 Projects         6                                                                                                         Total $S  1,111,1.21
            Total      $S       312,286                                                                                                  % $s  51%
            % ss   ' 14%                                                                                                          ApproVed/uh.f6nded            2'
         ,@r,proved/unfunded          0
                                                                                                                                  Dis6



        i4CER
         on-goin
                   9
                                                                                                                                                                N   CARE
               Projects   5    -                                                                                           DEMONSTPfiTIO'l OF           PATI
            Total     $S     270      476'                                                                                        on-Foing
            7. $S   13%                                                                                                                  a Projects   4
                                                                                                                                         tat      $s      414,246
         Appr,)ved/,.inf-i.inded      0                                                                                                  To
         I)tsappr,3vecl 01                                                                                                               %$S @ 19%
                                                                                                                                  App    ovedfunfund     d      0
                                                                                                                                         r
                                                                                                                                  Disapproved  0
         On-going
               Pro
                    $s          258,740
               ss 12%
                                                                                                                                                       M
         ,',I,,,rc,v,d/tst)ftsn(ied   0                                                                                       "SEAFCII & DFVEI.OP          NT
                                                                                                                                         -going
         lift'ir,p,roved 0                                                                                                        Oil
                                                                                                                                         Projects     0
            y                                                                                                                            Total $S 0
                                                                                                                                         $s
                                                                                                                                         %
                                                                                                                                             O/
            1 Projects  0                                                                                                         Appr.,,cd            utifti@dcd0
            .Metal  $s   0
                                                                                                                                  Disapproved 0.
               $so  -
            Droved/ittiftin(lcd       0
         rp@
                11 r


     ,,,!-k-fED DISEASES
                                                                                                                                             &
            O,i-t,oinp,                                                                                                ADMI:;ISTRATIO
               'J Projects
                                                                                                                                  On-@oinr
               Tot,il     SS     89,908                                                                                           -1     Projects     -      Core
               % $s   4%                                                                                                          T.t.1  ss          666p5O6
            Approvcdlunfutided           0                                                                                        7.    $S 3 07o
            Dis,@ppr ved                                                                                                     Apl)rove-I /,in f iiiided     0
                                                                                                                             Di.,I.,ii)proved  0
                               & GENERAL

               ,'I  Projects   8
               'rotlit     ss      593,957
               7. ss  27%
            t,ppro-.jc,l/iinftjntl-?d    2
                               0


                CORE
            Cn-r,oine

               Total  $s   666,506
               7  $s- 30%
            @PI)ro-;i--ri/titifunded     0                                                                                                                             I..: ... I
            Di..-,,ir)Droved   0                        .    .



                                      .   .                  I








                                                                          -37-
                                                                     Region          North Carolina                                Page 2       of:2





                   Pr         ed                                                                                     Pro
                                                                                                                           closed
                                                                                                                            @ir              TYPE OF ACTIVIT'
                              I.REAIE C!,'rEGORY                         4th YEAR
          CO,4PONENTS                                                                                                           @es  TC@ OB
                                                                                                                    TRAINI.NR AND EDUCATION
       EART
                                                                                                                               Projects        21
               Projects       6                                                                                             Total ss   1.627,712
               Total $s 377,31.0                                                                                              .$s  42%
               % ss  9%                                                                                                     %
          Approved/unfunded            0                                                                                   Approved/unfunded 2
                                                                                                                              approved      0
          Dic,ippi


           @NTER
               i? Projects       6                                                                                                          PATIENT    CARE
               Total     $s      462.545
               %$S il%
                                                                                                                                projects        8
          Approved/tinfunded           0
                                                                                                                             Total $s 1,353,445
                    ved  0
               r- p@p r 11                                                                                                   %  $9 35%
                                                                                                                           Approved/tinfunded 0
          'VROKE
          On-yoing                                                                                                         I)ilapproved__O
               Proiects       1
               tal  ss           207,000

                                       0
                                                                                                                     RESEARCH & DEVELOPMENT

                                                                                                                                Projects        0
         'ID'IFY                                                                                                             Total $SO
                                                                                                                             % ss 0
               it Proiects
               Total-ss    486,550                                                                                         Appro,.,ed./unftjiided   0
                                                                                                                           Disapproved  0
               $S 1!3%
          Appro\,Ld/tiiifunded         0
               il;tol)roved   0

     Pi-',T-ATED    DISEASES

                                                                                                                                             'Nl*
               @k   Projects  2                                                                                   ADMl'cilSTRATIO'@q   PT-j',h   4G
               Total      @      186,455
                                                                                                                        I Projects Core &          Develop.
               '7i $S
               Approverl /@in f un(led 0                                                                                Totit ss 894,021
                              0                                                                                            $s 23%,
                                                                                                                     AI)prove(l/tinfuii(led   0
                              & GENERAL                                                                              t)liiil)proved   0

                Proj,-cts  13
               Total $s  1,261,297@
                         34%
               Appro-,i,id/tinfunded   2
                  proved      0

      CORE AND DEVELOPMENTAL
                Projectz(7,ore & Develoo.
               Total     $S      094.021
     07        $s        23%
               @ppro,.,erllun[Lliided  0
               Di-,Ipproved   0









                                                                                                                                                                                 REVISEbL3/16/71
                                     j7D
                                                                                                                                                               R F  C,  't\      North  C,@i:oli'r,,

                                                                              LI 7@.,   r@, li TO'                            04                  PEi@'LC-D                      Trien.nium


                                                                 ;c                                                                         NZW
                                                                                                                                              1 V 1 T. I C-        D      F, C T               -%rCT
                                                                                                                         /1,;@7 Ft-N.                                                  T    7,4'
                                                                                                                                                                              -200,000
                                                                                                                                                           200,000@
            c C,                                                              694.02'-,                                                                           i       694,021            2,5  @o                                '@7
                              &     ac:;,2-,rcii      in
                        t, c        i     'ee d        a r e                                         216,798                                                              216,790@             40,517
                                                                           94,605
                        CC      T,::i                                                                                                                                     94.60;               20,885
                                  z:      o r,,-, u    a t i n             6  2,  5.5,)                                                                                   -52.550-'            i  6,e3.                     77      2
                                      r-,-..ncer                                                25,975                                                                    25,975
                         c;   i,: c,  1, i        v                        2L-.039                                                                                        24,031)              6  4     1
                                                                                                                                                                          11,075                  3 F- @i                   -
                                                                                                11.075
                              -n    Dc. --.t i                                                  69,925                                                                                         12, 7 @4-,                   8 2     2 2
                                                                                                                                                                          69,9,-S
                                                                                                                                                                                                                            7
                        C",   ic,-                     Trcr.@?ists                              67,182                                                                    671                  12,718
                                                                                          i     62,'j8S                                                                   6",383               12,55S
                                                                                                       7,050                                                      i              7,050                  6                           3
                                                                                                                                                                          p (5 -. C),                                             -I7

                                                                                    '@5
                                                            s c s -        53,
                                                                                                                                                                          53,/@35              i5,5-@6
                                                           Pro-,-.            169,65.-z                                                                                   169,662              36,893                         2C,6,55.i
                                                                                                                                                                                                                            oc      )q
                                                                                                                                                                          86,F,60              2?-.249
                                                                                                                                                                                                                                    2
                                                                           7),9                                                                                           7.2
                                                                                  -8
                                                                                                                                              95,846                      c,5  4-  0) i       15.24
                                                                                                                                                      4@O                 4SA@rO                                                    77
                9             zo-  F'-
                                                           and
                                                                                                                                                                          102,086              1 3@3                            115,403
                                                                                                                                                                                               12,1.1
                                                                                                                                          'I'   2,    805                                                                           7
                                                                                                                                                                          112,8'k)5                     2
                                                                                                                                              2 7@,.L                     27,476                                                    5
                              -cr                                                                                                             91,  9  t()                 @)i  .   919
                3                                                                                                                                                         29,017               6      23@
                                                                                                                                                                                               4.1    S55                23.
                                                       -:,In t IC                                                                             9'1575                               575
              ,3
                          c-.                                                                                                                         74-
                                                                                                                                                                          2'u 2. 6 @),4        22, itiO
                                    lo-o,.  in         C                                                                                      69,699                                                                        'C-5,   '?7
                                                                                                                                                                                               3,C)03                               c;
                                                                                                                                                                  7       123,@,05
                        Ca:@ c  c.  r  L I c .      Crii                                                                                      -@6,900                     26,900               4,    9C)2                           0 !I.
                                                                              1,264,639              667,393                            ;1,94'@1,946                         3,875,178            760,724                    4,635,5@O@

                                                                                                                                                                                                                           GRz-312171







                                                        CD


                                                                                                          TZ7"@ 1',             07  R-Q7;EST                          05
                                                                                                                                                                                                       I ('D




                                                                                                                                                                .,jl-TSLY
                                                                                                                                                           PR      U      t; N-          AC- 1,; 7 'j: 7                          c                                              TO@
                                                                                                                                                                                           ZOO,          000              Z.)O,        L)OU                             i        200,          C,00
                                                                                                 763,423-                                                                                                                 763..L23                  '      77      365      1    ,    04-@,     788
                                                                                                                                31       ',S"                                                                                                            7     5'-   7
                                                                                                                                                                                                                            94,
                                                                                                                                94,5C-4                                                                                                                2-         -,6,                       3
                                                                                                      2,
                                                                                                                                                                                                                                                         6,77    7                  36     -608


                                                                                                                                                                                                                            I!     @'j7   5                    3O@   5
                                                                                                                                                                                                                            5  S  ,                    13 . 5-.-@                   71.
                                                                                                                                                                                                                                                                                         - -  _;  @j
                                                                                                                                                                                                                                                       L3,733
                                                                                                                                       5
                                                                                                                                         .@06                                                                               5                          L2,         -,3

                                                                                                                                                                                                                                                                                 2
                                                                                                                              2-@@-,        126                                                                           2!2,        '--25            2             3
                                                                                                                                                                                                                                                                                    6 C, ,   7
                                                                                                                                49,3         21                                                                             4     9   --i2l            17@156

                                                                                                                                                                                                                                                                                    5
                                                                                                                                                                                                                                      2 -3
                                                                                                 114:220
                                                                                                                                27,    C@7    0                                                                                                          5, 0 4  9
                                                                                                                                                                                             9-'         461
                                                                                                                                                                                                                                                                                 47    1    3    57
                                                                                                                                                                                           395,          166              395,          IA6            76         -,91
                                                                                                                                                                                           130,300                        13G,         3iju            15      Z52                    5 , 5
                                                                                                                                                                                           107.436                        107,    '-36                 1
                                                                                                                                                                                                         96
                                                                                                                                                                                             97          437                97.
                                                                                                                                                                                                                                                         -,c4@
                                                                                                                                                                                             34,     137                    3
                                                                                                                                                                                           209.aC)O                       20').@oo                     44.30@
                                                                                                                                                                                             9,5.71'                        96,7@l-                    I,-,,  7  5   9              14    4     -t)                                  t
                                                                                                                                                                                           203    ,     C,95              2C)3,         095            23         2C)S           2 2 @i
                        "3i
                                                                                                                                                                                             7  9,   975                    7 9. 97                    19, 2,5  5
                                                                                                                                                                                           134.603                        '@34
                                                                                                                                                                                                                                         03            37,-
                                                                                                                                                                                             27   67   0                                                                            32,  81   7
                                                                                                                                                                                                                            27,670                       5,-J.@7




                                                                    0 T AL,                      919.949                            839,998                                           1     831     437                   :3,591.-384                    775,729               4,367,113













                                                                                                                                                                            Ail
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                                                                                              9                                                  34@
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                                                                                               98.lv


                                                                                               28,478



                                                                                                                                                              026,060        @3,324,850
                                                                                          :1,892,190         3,559@,493@i   '.762 337       4,321,835
                                                          827,543
                                       839,765




                                                                           (A Privileged Communication)



                                     SIZZI,@RY OF REVIEII t.,ND CONCLUSION OF
                                          APRIL 1971 REVILli CO@ftaTTEE

                                   NOWTII CTSOLINA REGIONT@L MEDICAL PROGRAM
                                                  RM 00006 5/71

                             FOR  CO@ISIDERATION BY I.IAY 1971 ADVISOI',Y COUNCIL


             RE,CGW.ENDKTION:     Approval in the reduced amount of $2,049,000 each year for
                                  three years.  The recommended level of support does not
             incl-Liep-,CollsideratioA  of  the  renal  disease  project   #28   which   was   submitted
             fbt  review  in  competition   'for   RMPS   funds   earmarked   for   kidney   disease.
             Reviewed  by  a   special   RMPS   study   group   meeting   simultaneously   with   the
             Review Committee, the renal project was deferred for a site visit.
             Computation based on the 04 year request is as follows:

                                                                           Direct Costs
                                                               Re     steq              Recommended
             Core                                            $    69Z@,021             $   694,000
             Continuation Projects                               5701818                   355,000
             Renewal Projects                                    667,393                   100,000
             New Projects                                       I;-942,946                 700,000
             Developmental                                       200,000                   200 2 000
                                                 Total-         $3,875,178             $2,049,000

             Costs   requested   and   recommended   all    years:

                                                                           Direct Cosl-s
             @e atioaal Years                                      itepted              Recommended
             04                                            $    3,875,178              $    2,049,000
             05                                                 3,591,384                  211049,000
             06                                            @3   ',
                                                                 7@0, @9 8             2@@9..P-LO

                                                Total        $1.1,026,060              $6,147,000
                  I UE:  The report of the November 17-18, 1970 site visit was presented
                           by  the  chairr@in  of  the  site  team.  Now  in  its   5th   year   (3rd
             operational year), North Carolina was one of the earlie,,ot regions to
             begin  active  Pd4P   planning.   From   the   inception   of   planning,   predating   the
             legislation, the deans of the three medical- schools and the North Carolina
             School  of  Pi-iblic  Ilealth   have   worked   closely   together   providing   leadership
             and  good  university  back-up  support  to  NCP@IP.   At   the   onset:,,they   sold   the
             program concept to the leadership of the State Medical Society and also
             involved  the  head  of   the   State   Health   Department   and   key   persons   from
             the Medical Care Coti4pi-rsion.  Incltiding the hospital association and
             key   health   agencies,   these   outstanding   resourc6s   arc    continually    involved
             in. the Regionts activities.  Rappi.-oa--'.ftient betvieer. white             non-xdhite







           NORTH CAROLINA Pi4P                   -2-                   RN.  00006@5/71

           cori-.miunities.was evident by recent integration of hospital-care facilities, State
           Medical Association and. cooperative assistance  by  R@iP  in  OEO  health
           center planning in Durham.  About 50% of the private practicing,physici-@ns
           have accepted the  need  for  trained  medical  assistance  in  their  practices.

           Major health care problems in  North  Carolina  include:  one--t-@alf  of  the
           hospitals  are  under  100-bed  capacity;  large  rural  population;  approximately
           17% non-white population with predominance of low socioeconomic whites
           and non-whites; and  diminishing  ratio  of  physicians  in  rural  areas--
           majority of whom will reach retirement in 10-15 years.
           As viewed by the visitors, the goals are compatible with the Region's
           needs. A  dichotomy  exists  at  the  top  of  the  organization  structure.  There
           is a PA-C but the power is  in  the  Board  of  Directors.  Subsequent  conmiuni-
           cations from the Region indicate this  problem-  is  in  the  process  of  being
           solved by the amalgamation of  the  two  groups  into  a  single  governing  body
           to be named the  Regional  Advisory  Council.  There  will  also  be  an  Executive
           Committee to conduct  business  during  interim  meetings  of  the  R-AG.  Although
           there are some gaps in  the  composition  of  the  RtG  (blacks,  allied  health
           representation and  consumers),  the  leadership  is  stable  and  interested  in
           the NCIIIIP. Since assuming the  directorship  April  1.970,  the  coor  -
           nator has strengthened the planning    and  administrative  functions   of
           core staff, and has demonstrated solid ability to continue his succes8or's
           leadership with an improved organizational approach  needed with the rapid
           development of  new  programs.  The  core  staff  are  extremely  competent  with
           a good record  of  planning  and  excellent  data  gathering.  The  deputy
           director, a  new  position,  appears  to  have  excellent  administrative  control.
           Fiscal management is  that  of  Duke  University.  The  Stroke  and  Heart
           Directors seem very capable and a Cancer Director is being recruited.
           The Planning Director,  also  a  capable  evaluator,  appears  to  be  outstanding.
           Cooperative  arrangements  are  excellent.  With  the  exception  of   the-Black
           Medical Association, nearly  all  health  agencies  have  been  drawn  into  -
           planning  and/or  operational  activities.   Although   sub-regional   activities
           exist at  different  rates  and  in  varying  locations,  specific  sub-regional
           lines have  not  been  developed.  Though  data  gathering  has  been  excellent
           and provides a base, good evaluation  has  n6t  been  bti.ilt  into  activities.
           With the new core staff planning section, this problem will probably be
           corrected.

           Progress reported by the site visitors includes: III expan8i     on  of  coronary
           care units from 6 to 60  hospitals  in  the  state;  establishment  of  self--
           supporting coronary care units  in  the  State  of  Franklin,  where  gross
           mortality has fallen from 28% to 14% in a  chain  of  riii.-nl  hospitals;
           2)  Establishment  of  effective  community  hospital  stroke   rehabilitation
           programs in 1/3 of the 100 counties of the statc-@---ai.-i outstanding          s'Ll-
           ment that might serve as a  national  model;  3)  An  out-teach  cancer  chemo-@
           therapy program has been developed in about 1/3 of the counties in the west,
           involving 130 physicians, which-has altered physicians' attitudes and
           behavior in. caring for this disease, as has been the case in the stroke
           program; 4)  An  extensive  back-round  for  cooperative  medical  activity
                                           C,






            NORTH CAROLINA PJIP                    -3-                    RM  00006   5/71
            has-been developed between medical schools, the health department,
            hospital association, and'the medical profession; 5) A detailed health
            data base  has  been  collected  and  published,  has  provided  a  guide  for
            future  planning;  6)  Programs  of  physicians  assistance  have  been   aided
            in  their  development;  7)  About  16,000  children  have  been  screened  for
            -murmurs,  with  3/1,000  suspects  found.  Other  projects  in   continuing
            education (cancer information service, central cancer registry,
            cardiopulmonary resuscitation, continuing education for Physical therapists,
            dental education, continuing education in internal medicine, education
            and.research in community medical care., heart consultation, and education,
            tumor tissue registry,   .   trophobl-as-tic  center)  have  not  y.et  received   full
            evaluation by their proponents or by core staff.
            Chief weaknesses identified by  the  visitors:  1)  RAG  cori-Tositi.on  and
            role;  2)  eliminate  control  of  program  by  the  Board  representing  medical
            schools (strength in the past but now a potential weakness); and 3) core
            evaluation input into pro-ram.
                                        0
            The Committee concurred with the site visitors that this is a good
            Region worthy  of  ranking  in  the  upper  20%  of  all  regions.  However,
            disappointment was expressed in the-number of project renewals proposed.
            With  one  exception,  the  stroke  project  scaled  down,  the  Committee  could
            muster  little  enthusiasm  for  support  for  renewal  of  projects.  It   was
            ,believed that the Region  must  come  to  grips  with  phasing  out  support  of
            projects and reinvesting in new activities.  With regard to the projects
            in  the  continuation  part  of  the  application,  the  Region  should  begin
            now to phase out RIIP support at the end of the currently approved
            periods  i.e.,  choriocarcinoma  project   #17R   should   be   self-supporting
                                                             'thout   being   detrimental,
            after three years.  it is understood that wi
            some activities may require longer phase-out periods.
            The Coi-nmittee noted that three projects with continuation  coiiii-i.tm.ei-its
            were not priority ranked.  These are #3R - Diabe.tic Consultation,
            #5R " Medical,      ar , and #19 -       si@ian  Assistants.  Concern,   was
            expressed about  the  relative  priority  (16  ever  26)  of  the  renal  disease
            project  #28;  (The  Committee  agreed  wholeheartedly   with   the   Region's
            r-ating  the  Cancer  Telephone  Conference  project  #38  least   important.)
            Some concern was also expressed about project #32 - Career 1,@icider
                            i n  which  seems  to  be  basic  education-  This  project,
            9               rity by the  Region,  falls  into  a.  "grey"  area  regarding
            eligibility for RMPS funding.  Committee understood that this issue. @1,11
            be discussed by the @lay 1971 Council.
            RMI:'S RENAL DISEASE AD IJOC PANEL  CRITI         The Panel recognized the need
                                                 for a statewide program and felt that the
            applicant should be commended for their efforts in attempting to develop a
            statewide plan for all pa@i@@,Lts with end-stage renal disease.  A site visit
            was recommended to evaluate duplication of services in dialysis, transplan-
            tation, and tissue typing.  Considerable redirection is needed, as well as
            budget reduction.

                                                             GRB!rll@S  4/23/71




                                                                Ohio State RM 00022
                                                                Northwestern Ohio RM 00063
                                                                North Eastern Ohio RM 00064
                                                                Ohio Valley RM 00048


                                      STAFF OBSERVATION

                                 REGIONAL 14EDICAL PROGRAMS IN OHIO


           The State of Ohio is covered by four Regional Medical Programs:
           Ohio State RMP comprises 61 counties in central and southeastern Ohio
           and is centered in Col-umbus.

           Northwestern Ohio RMP comprises 20 counties  in  northwestern  Ohio  and
           is centered in Toledo.
           Northeastern Ohio RMP comprises 12 counties  in  northeastern  Ohio  and
           is centered in Cleveland.'

           Ohio Vall    RMP includes 14 counties in southwestern Ohio -- the rest o
           this Region is composed of most of Kentucky and  parts  of  Indiana  and
           West Virginia.
           The attached map shows  their  geographic  relationship.  The  estimated
           population served by each (after adjusting for overlap) breaks out
           as  follows:

                                                           Estimated Population

                                Ohio State                      3,250,000
                                Northwestern Ohio               1,260,000
                                Northeastern Ohio               4,100,000
                                Ohio Valley                     2,070,000 (in Ohio only)
                                                              10,680,000

           Three of the Regional Medical Programs (Ohio State, Northwestern Ohio and
           Northeastern Ohio) have identical anniversary dates and have submitted
           applications for the current review cycle.  The attached chart compares
           selected characteristics of these three Regions.

           It is difficult to determine the extent and/or quality of cooperative
           ventures  among the three Regions, although some common activities are
           reported  in the applications:

                  1.  Health Careers in Ohio
                  2.  Ottawa Valley Continuing Education Council (Ohio State and N.W. Ohio)
                  3.  Planning for regular meetings among coordinators and core staff liaison
                  4.  Preliminary discussion regarding a comprehensive kidney program
                      in Ohio
                  5. Formation of Nurses' Coordinating Council for Continuing Education





                                                                                  0 [.1. I II-)
                                                           Districts Estab!ishcd Jcruary 29, 1968-

                                      Map of Conaressional Districts, Counties, and Selected Cities
                                                                              (24 Di'sticts)
                                                                                                       Northeastern Ohio              RYi?
                                                                                                           12 Counties
                       Northwestern Ohio                                                                     Cleveland
                          20 Counties
                              Toledoiw





                                                                                                    YPIA


























                        OA-At
                                                                                                                                            9t,
                                                                                                 RK

                              F"
                             DAYFC

                                                                                            ci
                                                                                         CASTE









                                                                                                                                                     re


                                                                                                                                                     es
                    CINC@l,4A
                                                                                                                                         Columbus





                     Ohio Valley RMP
                       14 Counties
                 overlap with Ohio              Statc



                                       Coutily will !,,@o c)r rr-orc Conciressioriol D;stricts





                                                                                Till@ll'IE  R@lPs  IN  OlilO


                                                                                       OlIfO                                                                                        oli!O



                           ilo            ol I 11,;'

                                                                                                                                       02                                             Di
                                                                                           0
                                                           (f)                            $9           3                                       33,-)                            $690,       187
                               Core  SupporL                                           $ 5.-@    2/A   5                                                                     ($445,250)
                                   Prrijects                                                ($i,40,c@48)                            ($44(@,132))                             ($244,937)
                           R(4(lues'L(-,d                                                     $i,832,892                          $]-, 3'z-, 4, 5 19                            $995,597
                           N(@xt@  Ycar
                                                                                   R(-clt!c@stecl                                 Reqtlested                                 Not  Reciuested

                                                 &

                               mc-@di@c@al           Scloc)l                               one                                        one
                                                                                           14                                                                                         21


                                                                                                                                        3                                              6


                                                                                           3.5                                          0                                          4   2

                                      Scliool@s
                                (,ericral  liospitals/Beds                          1  2  7  /  17   000                           36 /4 900                                65/16,545

                                                                                                                                                                                four
                            Nur@ibc@r      of       SIIISAvs                               f.1 ve*                                   two

                            r@i n t @A@@n c_y                                       Ohio           State
                                                                                              Universdty                       of             at  Tc,].edo

                                                                                                                                                                            Case  Western
                                         L% F@@L                                    Oliic,         State                       medical.                                         ReF@erv(,
                                                                                           Urii@/c,rsiLy                       of  Ohio  it  'il,oacdo                      Unive   rs   1    t



                                              A(Ivi.@ory  C;rotip:

                                                                                                                                     10                                         71
                             NLII@ib(-,r  of  M(!illl,)(@i-s                               34
                                                                                       tlirec-@                                    I our                                        four
                             Nuii@bc@r     of     Aiiriti@@l
                                                                                           14. f@ill@-ti,iiie                        7  ftil.l@-t:inic!                                full-time
                                                                                                                                     5  part                                      0  part-time
                             core.  I,CrsOI,4-",Ci                                           3  part-time


                                                                                                                        r      Weak  Administration                         Absence          of
                                         Coiic@  ei-ii@  of
                                                                                                                                             -inag(-,inciit
                                                                                                                                   aiid  @l,                                ,oordiiiator
                             Staff  l@eview                                                                                                                                 Critical  Sta47f
                                 for  I)etai.is)                                                                                           I)crsoni-iol-                    Corsui,-@rr
                                                                                     Progratfi DirL,(:tlun                        l,ack  of  P-kG                           Rept-(isentaL4.@)il
                                                                                     Affect  of  Grzilitc@e
                                                                                                       t                            Ilivol.vkriic:cit


                                                                                                                                                                                ki




                                                                                                              @y











                                   REGIONAL MEDICAL PROGRAMS SERVICE
                   SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION
                                       (A Privileged Communication)



            NORTHEAST OHIO REGIONAL                                 RM 00064  5/71
             MEDICAL PROGRAM                                        April 1971 Review Committee
            10525 Carnegie Avenue
            Cleveland, Ohio 44106

            Program Coordinator: David Fishman, M.D. (Acting)



            This region currently is funded at $690,187 direct costs for its first
            operational year ending June 30, 1971.  The 01 year award included indirect
            costs of $47,420, which represents an average indirect cost rate of
            appr@niately seven percent.  The Region submits an anniversary application
            which requests 02 year support as follows:

                  1.  Continuation with committed monies of core and three
                      ongoing activities.
                 II.  Funds for continuation of one ongoing activity for which no
                      monies have been awarded -- it was initiated during the 01
                      year through rebudgeting.
                III.  Supplemental core support.
                 IV.  Funds for implementation of two new activities.

            A breakout of the 02 year and partial 03 and 04 year requests are included
            as pp. 12-14 of this document.

            Although no site visit to the NEORT is scheduled, staff review of
            the continuation portion of this application highlighted certain areas
            of concern in which the Committee and Council reviewers may be interested.
            These are noted briefly below and discussed in more detail on pages7
            9  of this summary.

                  1.  The absence of a Coordinator and critical staff members.
                  2.  Lack of significant consumer      representation throughout the
                      regional committee structure, except for the newly reconstituted
                      RAG.
                  3.  Relationship between the Board of Trustees and the RAG and the
                      question of where decision-making authority rests.





          NORTHEAST OHIO                      -2-                    RM  00064   5/71
          REGIONAL MEDICAL PROGRAM



                                     FUNDING HISTORY

                                     (Planning Stage)                                           4
                                                                Funded
              Grant Year               Period               (direct costs)

                 01                  1/68 - 6/69 (18 mos)        $267,911
                 02                  7/69 - 6/70                 $462,663


                                    (Operational  Program)
                                                  Funded                Committed
          -Grant@ Year        Period          (direct costs)          (direct   costs)
             01             7/70  -  6/71      $690,187 1/                 -
                                                                            1,568 2/
             02             7/71  -  6/72         -                     $70
             03             7/72  -  6/73                               $707,56$



          1/ Based on a negotiated budget of $786,187 but adjusted to permit the
             use of $96,000 unobligated balance from the 02 planning year.

          2/ Recently reduced from previous commitment of $786,,187 because   of  RMPS
             fiscal constraints.



          .GEOGRAPHY AND DEMOGRAPHY:  The Northeast Ohio Region includes a 12 county
                                      area with a combined  population  of  4,100,000,
          and has a well-developed, efficient, and accessible transportation and
          communication systems.  Five standard metropolitan service areas (Cleveland,
          Akron, Youngstown-Warren, Canton, and  Lorain-Elyria)  represent  the  major
          population centers.  The Case Western Reserve University School of Medicine
          in Cleveland is the only medical school within the Region. Cleveland,
          as the largest population center, is regarded as the major center for
          medical care, teaching, and research.  In addition to the Medical
          School and its affiliated hospitals, Cleveland has a number of outstanding
          medical facilities. Each of the other  major  cities  has  large  community
          hospitals with active postgraduate  and  continuing  staff  educational
          programs. There are 65 general hospitals  in  the  area  (excluding  10
          osteopathic) which have a total of 16,545 beds.

          HISTORY: This program received its first planning grant in January
                   1968. The Region  experienced  initial  difficulty  in  recruiting
          qualified personnel until Dr. Barry Decker was appointed coordinator
          in June of that year.  Since no actual planning activities were
          undertaken during the first five months, the coordinator received approval
          for a six-month extension without additional funds.  As a result, tile
          01 planning year covered an 18-montli period ending June 30,. 1969.
          Following the coordinator's a pointmenr-, appropriate  staff  was  recruited
                                        p






            NORTHEAST OHIO
            REGIONAI@ MEDICAL PROGRAM             -3-                     RM 00064  5/71


            and the design of  the  organization  and  strategy  completed.  Initially
            the Region concentrated on  developing  a  large  volunteer  organization
            of about 300  individuals  to  disseminate  information.  Data  collection
            needs were identified and publications on health-related data were
            compiled and distributed.  Strong ties with comprehensive health
            planning area-wide and state health planning agencies, and other
            institutions and agencies were developed.  The second-year planning
            award included increased staff  support  and  three  feasibility  studies
            in the areas of diabetes, libraries, and the development of a demonstration
            laser unit for intra-hospital television transmission.

            In February 1970 the Northeast  Ohio  Regional  Medical  Program  received
            a pre-operational site visit.  The  site  team  and  subsequent  Committee
            and Council reviewers agreed that  the  Region  had  demonstrated  capable
            leadership in developing cooperative relationships throughout the area
            and had involved large numbers of providers in the Committee and overall
            ,organizational structure, had  established  data  collection  mechanisms
            and a priority system, and had  recognized  the  need  for  strengthening
            evaluation processes.  Concern was expressed, however, that few consumers
            of health care were involved in the program  and  it  was  suggested  that
            the Region seek ways to involve these individuals on both the Regional
            Advisory Group and the  various  committees.  Of  additional  concern  was
            the relationship of the 14-member Board of Trustees/Executive Committee
            with the Regional Advisory Group.  It appeared that the actual responsibility
            of approval of projects and assigning of priorities was retained by the
            executive committee, which is self-perpetuating by virtue of appointing
            itself, and members of the RAG and various other committees.  The site
            visitors thought this served to diminish  the  vitality  of  the  RAG.  It
            was recommended that these problems be  remedied  by  developing  a  more
            democratic appointment system and returning responsibility for the review
            process to the RAG. It also  was  thought  that  the  intricate  priority
            system which had been developed might not provide the necessary
            objectivity. The  operational  application  which  the  Region  submitted,
            requested support for core and ten projects ( of which five were
            subsequently recommended for  approval).  An  01  operational  year  award
            for the support of core and three projects was  made  in  June  of  1970.
            A fourth activity subsequently was  incorporated  into  the  core  budget,
            and a fifth funded through rebudgeting of basic grant funds.  The
            Region's current distribution of funds is shown below:

                          Core (including Organization for                   $445,250
                               University Cooperation in Health)

                          #1  -I,ibrary Consulting Service                     24,112

                          #2  -Nurse CCU Training                              79,844

                          #3  -Strep Culture                                  104,807

                          #7  -Stroke Rehabilitation Demonstration           36   174
                                                                             $690,187





          NOI@'I'llf,"AS'F OIIIO
          l@l,'GLO@4AL MEDICAL PROGRAM         -4-              RM  00064   5/71


          ORGANIZATION AND STRUCTURE: The grantee is a non-profit Ohio corporation
                                      which receives fiscal  services  from  the
          Case  Western Reserve University.    The current organization structure
          of the Northeast Ohio Regional Medical Program consists of the following:
             1. The Regional Advisory Group with 55 members  meets  quarterly  to
                review policy,program and projects for submission to RMPS.
                Nominating Committees in each of the six subregional areas select
                representatives to serve on the RAG.
             2. The Board of Trustees with 18 members meets on  a  monthly  basis
                and maintains the dual responsibility of  acting  as  the  legal
                guardian of the RMP and as the Executive Committee  of  the  RAG.
                The Board selects its membership from a slate prepared by a
                Nominating Committee of the RAG.


             3. Categorical Committees (Heart, Cancer, Stroke, and Respiratory).

             4. Problem Committees (Education, Service, and Data).

             5. Subregional Area Committees (Central, Cuyahoga, Eastern Lorain,
                Northern, and Stark).
             6. Numerous Subcommittees and Task Forces as determined by Committee
                Chairmen and the Board of Trustees.
          The Committee structure of this Region involves the participation of
          more than 350 people throughout the area.
          Subsequent to the February 1970 site visit and Coinmittee/Council
          review, and in response to their concerns about the passivity of the
          RAG, its relationshi-oto the Board of Trustees and the  low  level  of
          consumer representation, the RAG appointed an ad hoc committee to recommend
          how it might better fulfill its advisory and approval functions and how
          the Reaion's administrative structure  might  be  improved.  The  final
          report of this ad hoc committee has been accepted by  the  RAG  and  is
          included as a supplement to the  anniversary  application,  along  with
          a list of the reconstituted RAG.  Briefly,  the  major  changes  which
          have been effected are:
             1. The reduction of the RAG membership from 70 to 55, and the
                reduction of the number of automatic appointments to RAG from 58
                to 10. The previous  organization  provided  for  the  automatic
                inclusion on the RAG of all members of  the  Board  of  Trustees,
                all committee chairmen, and two  additional  members  from  each

                committee.
             2. Greater diversification of RAG membership  to  provide  for  less
                physician and greater consumer and nonmedical representation.
             3. Changes in selection procedures for RAG and Board of Trustee members.







            NORTHEAST OHIO
            REGIONAL MEDICAL PL@OGRAM             -5-                 RM 00064  5/71


              4. Recommendation of the ad hoc committee that categorical committees
                  be de-emphasized and more reliance placed on  area  committees.

            CORE: The core staff includes eleven full-time professional personnel.
                  It does not include a Coordinator -- Dr. Decker resigned in
            September 1970, and program direction has been assumed by the Executive
            .Committee of the Board of Trustees.  This Committee also is conducting
            a search for a replacement coordinator. In addition  to  the  Coordinator's
            position, there are four other professional slots unfilled.  The
            majority of the core staff is physically located in the central
            offices in Cleveland, with reigonal offices in Youngstown  and  Akron
            housing small contingents of core.
            During the past year, core staff has engaged in a plethora  of  activities,
            many the convenor/facilitator .,/broker type, and many in cooperation
            with various agencies and institutions. These are  described  on  pp.
            III-11 through III-27 of the application and shown on the chart on  page  2
            of this summary. Core staff also  implemented  the  Organization  for
            University Cooperation in Health (OUCH), which was approved as a
            separate project at the national level but  subsequently  initiated  as
            a core activity.
            The Northeast Ohio Regional Medical Program sees its  future  as  lying
            primarily in continuation and expansion of core  staff  activities  and
            cooperating with existing programs rather  than  emphasizing  project
            development.  During the coming year core staff efforts will concentrate
            in the following areas:
               1. A regional network of hospital-based  Directors  of  Continuing
                  Education with RMP backup services in evaluation and continuing
                  medical education.
               2. A regional health data system as a service  to  other  regional
                  agencies involved in health planning.
               3. A regional network of hospital-based "discharge planners" to the
                  continuum of other medical services.
               4. The planning, education, placement and  evaluation  of  physician
                  assistants in the hospital, inner-city  and  rural  environments.
               5. Developing relationships between  consumer  groups  and  provider
                  elements to improve health services to the poor.

             REVIEW PROCESS: Projects are initiated by any of  the  Northeast  Ohio
                              RMP committees or any non-profit agency  or  health
             organization. The core staff provides assistance  in  the  development
             of specific projects. All grant requests  are  reviewed  initially  by
             staff to insure inclusion of the necessary information  and  to  refer
             the requests to the appropriate committees.  All projects are referred
             to the local area committees for opinions regarding  local  applicability.






                                                                    Core Supported Activities  of \Iortlicast Ohio Regional vedical  Program
                                                                                                      Categorized  by Stealth Needs

                                                                                                                         y
                                      PRIORITY        4                                                     TYPOT,\T@'T                                        S IG,\, IF !CA                     PE3TI\EiT
                                        I;"\C,.':NT                                                                                                           Distribution                        Q@Ality
                                                                                          Prevention        8                  Deli%                                 0                                or
                           -,ieal,@h ServiceiNorr,-.@as-, Ohio !*"2                                                               of
                           ,\,e.@ds  of  the          organizational                                Detection              Health                              Health     Services             Medical Services
                                                      C,
                                                                                           Of         Disease
                                  Poor                  oal.@                                                                                                                                     Participation in
                                                      Ce.-,tralized        Data           Stroke                                OUCH                                                              kd   z
                                                                                                                                                             Ohio 'Hospital                            Ioc Co=ittee
                           @,ron Model                                                                 litation
                                                      Processing for                    Rehabi                                                               Association                          on Y@ical Educ@
                             Cities                   Lorain County                     Demonstration                    Discharge Planning                                                       t--'on
                                                                                                                         in Lorain County                     Seminars
                                                      Coordinatio-,                     Demonstration
                           C--.evbl---,ids               Ohio        -Reg-.onal         Need for Speech                  ".Respiratory and CE                                                     Pro-@essioaal
                                                                                                                         for Paramedicals
                                                                                                                                                                                                  Educatioa
                           v,-est. Side               ,-@',ad-'cal     Programs         Therapists         in
                           Citizen's  for                                               Community Hos@itals                    HCIO                                                               Programs
                           Better Health
                                                      Pea-.t.-i Data.                   Interagency Council              CE ii Nursing
                           @'a-roDolitan              System with                       on     Smoking      and
                           Ee:lt:r,,       Pi-arni-,ig, a.CH? Agency                    Health                           Kid-ney & Renal                                                          :-:Npansion 0-
                                                                                                                                                                                                  T'ea'
                                                                                                                         Hospital Study                                                                     Pro-ramS
                           Corporation                                                                                                                                                            at You-,i@.sz:oulr.
                                                                                                                                                                                                  State T;,-,i-vers-'@ty
                                                                                                                         Discharge Planning
                                                         ional Faalth                   Self-Instruction                 %4itli Metropolitan
                           .,i.ltipi-asic             R.2g
                                     ir,a. in         Data syst@@  (with                for         Diabetics            Health Planning Corp.
                           Screen
                           T r     u 1 1              f our Czp B agencies)                                                                                                                       stroice Filmstrips
                                                                                                                         Ra@iation Therapy
                           County
                                                                                                                         Guidelines  (wit,'
                           I!e,ilth I-:duca7  ,       Rehabilitation                    Development          of          Metropolitan Health
                           tiD.-.      'or       Better '.Needs    (with     CIT)       Regional          Tumor          Planning)
                                              of                                        Registry
                           Services by                                                                                   Pulmonary lqork Eval-
                           Urban Poor                                                                                      uation Clinir-
                                                                                                                         Coordination with
                                                                                                                         De-Dartment of Co@..
                                                                                                                         un:.ty Health

                                                                                                                         Students  from Un4-ver-
                                                                                                                         si@y of M4-chigan,
                                                                                                                         Un.@Lvers-'-ty o@' Cali-
                                                                                                                         fo--nia and Clk'RU


                                                                                                                         -'-Iealth Careers Day





                                             -7-
             NORTHEASI-OHIO                                         RM 00064 5/71
             REGIONAL MLDICAL PROGRAM


             Following review and modification, projects are submitted to the Board
             of Trustees for approval, priority rating, and referral to the Regional
             Advisory Group.
             REGIONAL PRIORITIES:  The current identified health needs of the Region
                                   and their priority ranking  remain  identical  to
             those formulated and submitted inthe original application for operational
             status a year ago. Each problem is classified on  a  scale  of  urgency
             (Urgent-4, Important-3, Significant-2, and Pertinent-1) and this
             scale is used in the priority ranking by the Board of Trustees of
             the projects that go through the review cycle.
                1. Immediate health service needs of the poor of the cities    of
                   Northeast Ohio (Priority 4-Urgent)
                2. NEORMP organizational goals (Priority 4-Urgent)
                3. Prevention and early detection of disease (Priority 3-ImportAnt)
                4. increase in the potential for the delivery of health services (Priority
                   3-Important)
                5. Equalization of the distribution of health services (,Priority
                   2-Significant)
                6. Improvement of the quality of medical services (Priority 1-Pertinent)
             Forty percent of each project's numerical priority rank is determined
             by this scale of the urgency of the health problem which is addressed.
             The remaining 60% is calculated on factors of regionalization potential,
             estimated effect, probability of success, cost-benefits, adequacy of
             evaluation and probability of self-support.  Included as page 8 of this
             summary is a chart showing the breakout by. health need category of
             the activities for which funding is requested in this application.
                I. Continuation Commitment:  Staff  has  reviewed  the  continuation
                                               portion of this application which requests
             committed support for core activities and three ongoing activities:  #1
             Library Consulting Service. #2-Nurse CCU Training   , and #3-
             The Program Coordinator, Dr. Barry Decker, resigned in September 1970,
             and staff reviewers experienced great  difficulty  in  evaluating  this
             Region and its potential for the future in the absence of either a
             Coordinator or a Deputy Coordinator.  There is no indication as to
             when a Coordinator will be found.  In addition, positions for Directors
             of Evaluation, Research, and Communications are vacant.  Although the
             descriptions of core staff activities are most impressive, the
             question of whether core will be able to maintain this momentum without
             Dr. Decker is moot.







                                      NORTHEAST OHIO REGIONAL MEDICAL PROGRAM ANNIVERSARY APPLICATION REQL-EST
                                                              CATEGORIZED BY HEALTH NEEDI/
                                                 PRIORITY 4                    PRIORITY 3              PRI?RITY     PRIORITY
                                                                                                                       I
                                                    URGENT                      @ORTANT               Significant Pertinent
                                   CORE         ealth      NEOR@       Prevention &  Del
                                             service                                      iver   of    Distr.
                                                          Organiza-               of  Health @ervice!: of Health  l@ullity Of     TOTAL
                                                                       Detection                                    e ica
                                             Needs of     tional Goals  Disease                        Services    Services
                                                                                           $101,601
                                                    47                               Library Service
            CONTINUATION            606
               .vith               Cori             re                                      CCU Trg.                             $803,696 2/
             Commitment                                                                     (funded
                                                                                           m  Core)


                 wi th
        Sdrplemehtal Fun s                                                                                                         50,145

                                                                                          91,756
                                   $50,000                                                onary Work
                                 Core                                                      aluation
                                  Supplement                                               arge Plan.
                                                                                          th Careers
                                                                                           Ohio                                   $1,41,756
                                                                                          unded from
                                                                                          re


         TOTAL REQUEST
                                                                                           93                          -0-


         I/This chart includes only those activities for which funds specifically have been awarded or requested.  It does
           not include numerous staff and core-supported activities which are outlined on pp. II-6 through II-8 of the applicatim
           and the chart on page 6 of this summary because of RMPS fiscal structure.
         2/The Region has requested the Council-approved level rather than the actual commitment of $786,187 which has since
           been  reduced  to  $707,568f









           NORTHEAST OHIO
           REGIONAL MEDICAL PROGRAM           -9-                        RM 00064  5/71


           Core activities during the past year have been varied and imaginative.
           .Good working relationships with many other institutions and  agencies
           are apparent, and substantial staff effort is spent in  convening  and
           facilitating activities.  The real meat of the NEORMP lies in the realm of
           its core functions. In fact, the application states  that  core  staff
           energies and funds can be used more efficiently and appropriately
           through cooperating with existing  programs  and  developing  several
           areas of obvious need rather than encouraging and submitting new
           projects for which funds are not likely to be  forthcoming.  The  staff
           consensus was that the core dollars in this Region generally have
           been used wisely.

           The February 1970 site visitors expressed concern about  the  relationship
           of the Board of Trustees to the Regional Advisory Group, as  well  as
           the lack of consumer representation.  Included as a supplement to
           the anniversary application is the Region's response.  The RAG member-.
           ship has been diversified and reconstituted and does,  indeed,  include
           much greater consumer and non-medical  representation.  However,  this
           diversification has not extended to the extensive committee structure,
           the membership of which is virtually entirely  provider-oriented,  and
           primarily physicians.  Also, changes have been made in selection procedures
           for RAG and Board of Trustee members, but the functions of  these  groups
           seem not to have been altered.  Staff had serious concerns as to
           whether the decision-making responsibility in this Region  rested  with
           the Board of Trustees (an appendage of the  grantee  institution)  or
           with the Regional Advisory Group.  RMPS should assist NEORMP in
           developing an organizational structure in which the RAG  can  operate
           without a watchdog.

           The extent to which there is coordination among the four  Ohio  RMP's
           is always a question.

           Staff recommended an award of $707,568 (reduction of the previous commitment
           of $786,187 by $78,619 because of RMPS fiscal stringencies) for  02  year
           continuation of core and three discrete projects, and that  its  concerns
           should be relayed to the Region with an offer of any possible  assistance.

              II. Continuation with Supplemental Funds
                                                                               Requested
           Project #7 - Stroke Rehabilitation Demonstration. This project      Second Year
                        was included in the initial operational request,         $56,145
           but the Committee/Council could not approve it, primarily  because  of
           its lack of clarity and because it seemed mainly to  support  patient
           services. However, the Region expressed such deep  concern  over  the
           rejection of this activity that RMPS agreed to consider a revised proposal.
           The Region's feeling was that this project  represented  an  activity
           outside of Cleveland and a sincere attmept to provide  better  coordinated
           care of stroke patients. The project was  considered  extremely  important
           to the regionalization process. July 1970 Council  reviewed  the  revised
           proposal and recommended approval in the time and  amount  requested.
           Although no funds were awarded for the conduct of this  project,  the
           Region elected to initiate it by rebudgeting monies from core.




         NORTHEAST OHIO                                             RM   00064   5171
         REGIONAL MEDICAL PROGRAM            -10-



         The present application requests money   for the second and third years.
         The revised proposal stated that efforts would   be made to  have  this
         activity self-supporting at the end of the third year.
         The objectives of the program include establishment of   a comprehensive
         ambulatory stroke care program and of a  replicable  model  of  this-type
         of care in a non-hospital setting, as well as a demonstration to
         increase public.and medical awareness  of  the  benefits.  Since  October
         1970 when the activity was implemented, thre  e new people  have  been
         hired, neurology and orthopedic clinics  have  been  established,  all
         of the hospitals and medical societies of the three-county area
         have been informed, and an increasing number of stroke patients is being
         served.
         Third Year:  $26,076                                                     Requested
                                                                                  First Year
            III. Supplemental  Core Support: Subcontract  funds  are  requested     $50,000
                                             for NEORMP's  contribution  to  the
         program Health Careers in  Ohio,  to which three Ohio RMP's are contributing.
         It is being conducted under the auspices of the Ohio  State  RMP  and  is
         centered in Columbus. Applications  int  he  current  review  cycle  request
         funding for the next year as follows:

            Ohio State RMP           $145,000
            North East Ohio RMP        50,000
            North West Ohio RMP        25,000
                                     $220,000
         Ohio Valley RMP  contributed  $5,000 to this activity las t year,  but
         has since withdrawn its support.
         Second Year:  $50,000                      Third Year:  $50,000


            IV. New Activities: Each of  these  two  projects  addresses  itself
                                  to the problem of improved  delivery  of  health
         services, and each received from the Board of  Trustees  and  the  RAG
         a priority ranking of three, on a five point scale.
                                                                                    Requested
         Project #11 - Pulmonary Work Evaluation  Clinic.  This  proposal  would    First Year
                       establish a  clinic  hich  woufd-accept  from  physicians     $37,353
         throughout the region referrals of  patients  with  diagnosed  or  suspected
         pulmonary problems; evaluate the degree of impairment in relation to
         his ability to work; recommend to the  physician  a  comprehensive  plan  of
         approach to treatment and  rehabilitation.  The  clinic  would  operate
         one day per week staffed by a medical team consisting of a clinic
         director, technicians, vocational counselor,  social  worker,  and  in
         selected cases, a psychiatrist. After a  study  of  the  patient,  the
         staff would confer to reach basic  recommendations,  especially  as  to
         his ability to hold a job and function in the community.  This would
         be reported in detail to the referring physician.
         Second Year: $27,909                            Third Year: $27,909







             NORTHEAST OHIO
             REGIONAL HEDICAL PROGRAM                              RM 00064  5/71



                                                                            Requested
             Project #12 - Discharge Planning for Continuity of Care,       First Year
                           Lora     ount . The aim of this project is to     $54,403
             establish a fully cooperative Discharge Planning Program under
             the County Health Department which will insure adequate care
             for the continuing health needs of patients in all hospitals  in
             Lorain County. This program will develop slowly;  starting  with
             one large hospital the first year, and expanding to five smaller
             hospitals and complete county-wide coverage by the end of the
             second year.

             Second Year $63,327





















                                                                       GRB/RMPS
                                                                       3/11/71






                                                                                                        C'@:1 Nort"tas@lern Olio
                                                                                                   rl,, rT

                                                                            02
                                                                                           '7 r.r, C,':,'




              Core                              606,748                                                 606"748       30,337      637,085
                                                                                         50,000         50,000       -0           50,000
              Core Supplemerat
                    liosoital Library
                                                                                                                      5,769       37,01'-)
                    co!psuitinz Services       31,243                                                   31,243
                                                                                                        70,358        5,429       75,787
              #2    '@Nur:;e CCU Training      70,358
                    ,--,I-.eur-.atic Fcver Prev.
                                                                                                        95,347        12,395      tO7,742
              #3    by Strep. Cut. Prop_"      95,347
                    @c'roke Rehab. Dem.
                                               50,145                                                   50,145        4,014       54,159
                    @@.j iect
                     u - L@. 0 r. -a
                                                                                                        37,353        0           37,353
              @xll- Evalu@tion Clinic                                                    37,353
                                                                                         54,403         54,403        0           54,403
              @-I 2- Diseliarge Pl,anning










                        -'7






                                                                                                                      57,944    1.053,54',.
                                               853,841                                    141,756-      995,597
                                                                                                                                C.RB  2r, /71






                                                                                                           Northe3stern    Obio

                                                               Cr RP@Ql',7ST  03                                       r-, y@e;   F@w)

                                                                                                                                         -7
                                CF             c cl'.",1 C7              P"@ilv ioc, "I Illy
                                                                                             7  '7             7 -,7  TZ r@ 7'
                       1:T

                                                                                                                                 0
                   Core
                                                                                          50,000      50,000        o         50,000
                   Core  Supplement

                                                                                                                                 0

                   i72                                                                                                           0

                                                                                                                                 0
                   i73
                   #7                            26,076                                               26,076     2,108        28,184
                                                                                          27,909      27,909        0         27,909
                   i7l2                                                                   63,327      63,327        0         63,327













                                                 26,076.                                 141,236      167,312    2,108        169,420
                                   T'l)@-AL
                                                                                                                           GRB  2/9/71








                                                                                                                              vortl,.cart    Ohio
                                                                     C-.,@ REQTJI;ST C,4   PERTOI)                              00OG4      5/71


                                                                                                                                %LL           ALI, YF'@'.RS
           T 1                                                                                                          L
                                                                           CTiv-l
                                                       AP
      OF                  ACI
                                                                                                                                606,748       637,0@05
         Cor-2
                                                                                                                  509000    1   150,000.      150,000
                                                                                          50,000
         Core Stipp.
                                                                                                                                               37,012
                                                                                                                                31,243

                                                                                                                                70,358         75,78'1
           2
                                                                                                                                95,347        107.742
         ;-3
                                                                                                                                76,22t         82,343-

                                                                                                                   27,909       93,171      i  93, lx7 I-
                                                                          27,909          @-",gog       0
                                                                                                                                              117,730
                                                                                                                                117,730
          @'L2-






















                                                                                                                                                  30@V,87%)
                                                                                                                    77,909      11,240,818
                                                                           77,909              09
               TOTAL                                                                      77,9




                                                                                             Nortliwest'Ohio RM 00063
                                                                                             Ohio State           Rlt 0002'z'



                                                   ST,.A.FF OBSERVATION


                                             OHIO    PJGIONAL MEDICAL PROGRAMS



                                                Health Careers in Ohio



                       ue,st:   Three   Ohio    Regional    Medical    Procyrains    have    requests    in    this
                               revie@.7 cycle for support of a tri-regional procram
                   Health    Careers    in    Ohio.    The    program    is    centered    in    Columbus,    Ohio,
                   under the aegis of the Ohio State P@IP,  and a centralized educational
                   information center has been established.   Other activities which
                   are in various sta.@es of development include:

                          An    inventory    of     training     and     continuin-     education     offerings.
                          A student referral service.
                          Programs  for students in secondary schools.- colleges,  and
                           universities.
                          Training    programs    for    educators    in    colleges,     junior     and     senior
                           high schools,  and graduate students.
                          Coordination    of    new    health     careers     educational-     offerings     and
                           assistance in developing programs.
                          Pre-professional     colle,,e     program-     advisor     and     student      programs.
                          Establishment    and    coordination     of     action     and     resource     health
                           manpower career programs.
                          Military     Service     Directed     Into     Health     Careers     (MEDIHC)-     referral
                           service.
                          Evaluation and analysis of the delivery of health services as
                           they    concern    health    manpower    and    careers    in    the    health    field.

                   Elaboration   on   these   aspects    of    theprograni    can    be    found    on    pp.    58-61
                   of the Ohio State @fP application.

                   The   total   funding   which   is   requested   for    the    coming    year    for    thi-s
                   program is $220,000.   The amounts which the three Rl,[Ps are requesting are:

                          Ohio   State   R@TL'           $145,000
                          Northeas@,      Ohio  P,"fP       50,000
                          Northxvest      Ohio  P@iP        25,000

                                          I'@@ fp               $5,000 to             activity     last     year
                   The Ohio Val--,.ey  '               -   t-
                   but has since -ai.tl-idrm@7n it-@ suip@.ort-..


                   iollps PO                 new '@@7'S policy on                 careers recruitment
                   precludes the use of                  fu,.),ds   fcr   direct   )pei-,-itioi-iai-   grant   support
                   of health careers                          T-.-i-ojec-tF7,,  al.tliotich  the  policy  still.
                   permits   the   use    of    core                            i-@iol-ii(-',s to stimulate
                   cooperative    ej'foi:!L-s,
                   resources,                                                                         agencies
                                                                                     @4@o       t'-h c a
                   to provide ne-.,-,                        '7or                                      T,(,ers.  The
                                                                     y                                    L
                   opinion of Ri,@)S st,-f@ is                                                           the 'i)oun,,Is
                   of D(--ri,@iissible




                                                                   (A Privileged Coimpunication)



                             SUMMARY OF REVIEW AND  CONCLUSION OF
                                 APRIL 1971 REVIEW  COMMITTEE


                          NORTHEAST OHIO REGIONAL   MEDICAL PROGRAMS
                                        KM 00064    5/71

                       FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL

            RECOMMENDATION: That this Region be funded at its committed level
                             for one additional year.

                                   CONTINUATION COMMITMENT

               Year                   Request                   Recommendation
                02                 $8033696 1/                   $786,187.2.
                03                      -
                04                      -
              TOTAL                $803,696                      $786,187



                                   SUPPLEMENTAL SUPPORT                -

               Year                   e u s@t                   Recommendation
                02                   $191,901                       -0-
                03                    167,312                       -0-
                04                    77  909                       -0-
              TOTAL                  $437,122                       -0-


                                   TOTAL A.,NNIVERSA Y@@U S@T

               Year                     uest                    Recommendation
                02                 $995,597                       $786,187  2/
                03                    167,312                       -0-
                04                   77   909                       -0-
              TOTAL                $1,240,818                     $786,187


            I/ Region requested more than   its 02  year  commitment.
            2/ $786,187 is the original commitment for these activities.  The new
               reduced commitment due to PMS fiscal constraints is $691,845.
              l@@E: The over-riding problem presented by this application and
                      pondered by the Committee concerned the ba7sic viability of
            the Northeast Ohio area as a Regional Medical Program.  Some of the
            specific questions raised in this regar  were:
                1.  Little apparent relationship between Regional goals and the
                    activities which were supported.
    Is          2.  The absence of a Coordinator and critical staff members (Directors
                    of Evaluation, Research and Comuiunications) and the question
                    of whether Dr. De6ker, the previous Coordinatori was the driving
                    force behind most Regional accomplishments to date.





                                                                        RM 00064    5/71
     NORTHEAST OHIO RMP                    -2-


              3. Generally unimaginative project activities.

              4. Although the Cleveland CHP-B agency is  one of the  largest  in
                  thelcountry, NEOR@ relationships with  that agency appear not
                  to be as extensive or fully developed as desirable.

              5. The fragmentation of the State among the  Northeast  Ohio,
                  Northwest Ohio, and Ohio State Regional Medical  Programs.


          In view of the above points, the staff concerns listed on  page   one
          of the yellow summary and the question of the basic  viability  of
          this Region (and parallel problems in the Northwest Ohio  and  Ohio
          State Regional Medical Programs), the consensus was that  the  NEOIOIP
          should  be supported for one additional year at its committed level,
          with similar holding actions being taken for NI@10 and OS R@IPS.  Each of
          the three Regions should receive a site visit to  concentrate  on
          that program's problems, strengths, and  weaknesses.  After  these
          three inforination-gathering visits, a second-stage consultative visit
          should include the RAG chairmen, Coordinators, sponsoring institution
          representatives, and other officials of each program  to  discuss
          amalgamation of the programs. The one year  continuation  of  the
          three separate KIPS, then, is viewed by the Review  Committee  only
          as an interim step toward the unification of Ohio.

          Continuation Commitment: Continuation funds were requested for
                                    Core and three ongoing  activities  (Library
          Consulting Service, Nurse CCU Training, and the Strep Cultur   e).
          The Review Committee agreed that the commitment  of  $786,187*  should
          be recommended for one additional year to support the  conduct  of
          these activities and other approved projects into  which  the  Region
          chooses to rebudget, within this level of funding.

          Supplemental Support: Supplemental funding was requested  for  the
                                 following:

              A.  Continuation of Stroke Rehabilitation  Demonstration  project
                  which has been initiated during the 01 year through rebudgeting
                  of funds.  Although no additional funds were recommended for the
                  continuation of this project, the Region is not prohibited from
                  exercising its rebudgeting authority for its  continuation.

              B.  Supplemental Core support for NEORMP's contribution to  the
                                                              t
                  program Health Careers in Ohio.  In view of  he staff
                  opinion that expansion of this program exceeds the  bounds
                  of permissible PMS support, the Review Committee recommended
                  disapproval supplemental monies for its expansion.

              C.  Supplemental support for the initiation of two new activities:
                  Pulmonary Work Evaluation Clinic and Discharge Planniilg  for


            Recently reduced to $691,845 due  to R7pi-PS financial restrictions






                  Continuity of Care.  Considering the enumerated problems
                  which the NEORMP is experiencing (even though the Discharge
                  Planning proposal was considered by some to represent the
                  most imaginative project in the application) the Review
                  Committee could recommend no additional funds for'the
                  initiation of these new projects.  The Region is not
                  prohibited, however, from beginning the activities throug@
                  tebudgeting if it chooses.







                                                                GRB/RMP
                                                                4/20/71






                                                            (A Privileged Communication)



                                REGIONAL MEDICAL PROGRAMS SERVICE
                    SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATIO'4t



               NORTHWESTERN OHIO                                      RM 00063 5/71
               REGIONAL MEDICAL PROGRAM                         April 1971 Review Committee
               1600 Madison Avenue
               Toledo, Ohio  43624


               Program Coordinator:  C. Robert Tittle, Jr., M.D.

               This Region currently is funded at $781,332 direct costs for  its
               second operational year ending June 30, 1971. The 02  year  award
               included indirect costs of $219,773, which represents an  average
               indirect cost rate of approximately 28 percent.  The Region submits
               an anniversary application whi,ch requests 03 year support of
               $1,324,519, as follows:

                   I. Continuation with committed monies of six ongoing activities.
                   II. Renewal of core support plus supplemental core support for
                      contribution to an inter-regional health careers  program.
                  III. Activation of two previously approved but unfunded activities.
                   IV. Initiation of three new activities.
                   V. Developmental Component

               A breakout of the 03 year and partial 04 and 05 year requests  is
               included as pp.11-13of this document.

               Although no site visit to the NWORMP is scheduled, staff review of
               the continuation portion of this application highlighted items of
               concern in which Committee and Council reviewers may be interested.
               Many of these are unresolved problems which were identified by the
               May 1970 site visitors and the subsequent Management Assessment Team:

                  1. A lack of strong leadership in the administration and management
                      of the region.  This weakness is demonstrated by:

                          a.   Inadequate core staff input into RMP  activities.
                          b.   Core staff functions, responsibilities, and lines
                               of authority not being defined or delineated.
                          c.   Project personnel headquartered in the Region's central
                               office being diverted to core staff functional activities.
                          d.   An apparent control of certain medical school
                               faculty over the Regionl8 day-to-day administrative
                               decisions.
                          e.   Serious shortcoming in core input into the financial
                               management of the Region.






         Northwestern Ohio
         Regional Medical Program                -2-                    RM 00063  5/71


              2. A lack of involvement of the RAG     collectively in the overall
                 planning of the  program.  Alsol,  the  Executive  Board  of  the  RAG
                 appears to  be  far  more  involved  in  direct  management  decisions
                 than is appropriate for a policy-making group.
             @3. Although core staff has been reorganized, certain specific
                 personnel questions arise-.

                       a. No minorities are identified on core staff.
                       b. Although the half-time position of Associate Coordinator
                          for Planning  has  been  changed  to  full-time  Deputy
                          Program Coordinator, his effectiveness in providing
                          strong  leadership  in  the  management  and   administration
                          of the Region has yet to be demonstrated.
                       c. While one of the Region's major objectives is in the
                          area of  continuing  medical  education,  there  is  no
                          core staff member identified who is responsible
                          for this effort.

              4. Little or no interchange    of  information  among  the  various
                 reference  panel  members  to  promote   inter-categorical   planning.

              5. Program outreach  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.

                                     FUNDING HISTORY
                                    (Planning Stage)
                                                                   Funded
          Grant Year                  Period                   (Direct Costs)
             01                      1/68-12/68                   $274,450
             02                      1/69-6/70 (18 mos.)          $471,337 1/

                                     (Operational Stage)

          Grant Year          Period           Funded (Direct Costs)            Future Commitment
             01               T/6-9-6/70              $49o,502
             02               7/70-6/71               $781,332                        ---
             03               7/71-6/72                  --                        $401,245 3/
             04               7/72-6/73                                             $20,830



          I/ Includes core support for 01 operational year.
          2/ Support for six operational projects - 01 year core included in 02 year
             planning    award.
          3/  Recently  reduced  from$445,827due  to  RMPS  fiscal   constraints.







               Northwestern Ohio
               Regional Medical Program              -3-                    RM 00063  5/71

               The current financial breakout for this  Region's  02  operation  vear
               is as follows:


                      Core                                       $335,200
                      #1-Stroke Education Program                 96,847
                      #2-Uterine Cancer Detection                 94,268
                      #4-Coronary Care Training                   161,517
                      #6-Action on Smoking & Health               30,021
                      #7-Dial Access Tape                         42,649
                     #15-Ottawa County CE Council                 20,830
                                                                 $781,332


               GEOGRAPHY AND DEMOGRAPHY

               The Northwest Ohio Regional Medical Program is comprised of 20 counties
               with an area of 8,635 square miles and a total population of approximately
               1.4 million.  It is an industrial area, with 90% of the employed population
               engaged in non-agricultuial  occupations.  Approximately  75%  of  the
               Region's population is concentrated in urban areas and 92% of the population
               is white. Transportation facilities  within  the  Region  are  adequate
               to assure prompt access to medical facilities, principally by Inter-
               state Highways and the Ohio  Turnpike.  Seven  major  railroads  serve
               the Region, in addition to two major interstate buslines and four
               major airlines. There is a new  medical  school,  the  Medical  College
               of Ohio, located in Toledo.  There are, as well 10 schools of
               nursing, seven of medical technology, 12 of radiologic technology
               and one of cytotechnology.  The Region contains 36 general community
               hospitals with approximately 4900  beds.  The  Northwest,Ohio  RMP  is
               joined to the south by the Ohio State RMII based  in  Columbus,  and
               to the east by the Northeast Ohio RMP based in Cleveland.



               HISTORY

               This Region had a two-year planning phase  during  which  time  core
               staff was recruited (Dr. C. Robert Tittle, Jr. appointed as Coordinator)
               and planning and data collection studies  carried  out.  As  a  result
               of the information compiled from these studies, the Region's priorities
               were established as:  continuing medical education, improved rehabilitative
               care, and better and more prompt diagnostic methods.

               A pre- operational site visit was conducted  in  April  1969.  At  that
               time it was noted that although the core staff was basically an adminis-
               trative organization lacking professional and expert technical backup,
               this weakness was counteracted by  an,active  and  devoted  Regional
               Advisory Group which was anxious  for  progress.  The  key  strength
               of the program was seen to lie in the active  support  of  the  private
               medical sector.  Good  cooperative  relationships  and  organizational
               liaison appeared to have been developed  within  the  geographic  area,
               but it was though that the relationship between  the  Program  and  the
               Medical School could be further developed  to  better  complement  eac
               organization.  Finally the site visitors agreed that the data collection
               emphasis had been on the generation of data  in  general,  with  little






           Northwestern Ohio
           Regional Medical Program           -4-                      RM 00063 5/71


           attention given to its program significance or effective use.

           A second site visit to this Region was conducted in  May  1970.  The
           need for this visit was born of Committee/Council's review of  a  request
           for a core increase. The site team was impressed with  the  number  of
           interested groups which had been mobilized to show  their  support
           for the RMP and the many apparent good relationships which had.been
           developed. Relationships between the Medical College  and  the  RMP
           seemed satisfactory as well. There was disappointment  over  the  lack
           of program outreach, most of the programs being concentrated
           in the Toledo area. The primary and  over-riding  concern,  however,
           was with the unsatisfactory core staff and its functions.  An elaboration
           of these concerns appears in the Core section of this summary, pp 7-8
           In view of the dismal discoveries about core staff,  a  Management
           Assessment visit for this Region was recommended, along  with  only
           one additional year's support for core, without the  requested  increase.
           The subsequent Management Assessment visit found  most  unsatisfactory
           core management, and the report was sent to the President  of  the
           applicant organization, the Medical College of Ohio at  Toledo,  for
           action. The present application discusses changes  that  have  been
           made.  See Core section of this summary.

           Regional Goals: Five program priorities for the coming year are listed
                           in the application:

               1. Updating the skills and attitudes of  existing  practitioners
                  of all health professions.
               2. Cooperation in the development of adequate  facilities  for
                  preventive and ambulatory careof all age groups.
               3. Development of Inter-regional Coordination among  Ohio  and
                  adjacent RNPS.
               4. Facilitation of Continuing Educational Opportunities.
               5. Cooperation in the upgrading of Manpower  Resources.

           The chart on page 5 of this summary shows the relationship of ongoing
           and proposed projects to the above five program priorities.


           RAG and Committee Structure:  The RAG is composed of 50 members and
                                         meets quarterly.  Its  Executive  Committee
           meets monthly with core staff to facilitate the administrative super-
           vision of the program. All actions of the  Executive  Committee  are
           subject to RAG review and any fundamental questions of  policy  are
           referred to the full group., The NWORMP is divided into  four  subregions
           and each is represented on the RAG,and Executive Committee.  In addition,
           there is a Continuing Education Planning Committee  for  Non-Physician
           Health Personnel in each of the subregions.  Four  categorical  reference
           panels act as advisory groups to the RAG.  There are five other groups
           in the areas of lower respiratory tract neoplasms
                                                              continuing  education,












                                                                 NORTM4ESTERN OHIO REGIONAL MEDICAL pRCCR.1,M AN,'IVE.RSARY REQUEST
                                                                       Categorized  by  Regional  Program  Priorities  03  Year-
                                                     Updating Skills &           Devel. Faciliti                  ional
                                                     Attitudes of                for Preventive                   ion             Continuing                             Total
                                      Core           Practitioners               Ambulatory Care                                  Education                              Request
              Continuation                          Stroke Rehab. Trng.          Uterine Cancer          Ottawa Valley         Ottawa Valley
                                                                                  Control                CE Council            (see inter-regL Coord.)
                                                    Dial Access                                                                                                        Committed
                                                    Intensive Nurse CCU  Trng.                                                 Smoking & Health                        $48'1,817
                                                       $331,454                   $97,188                $20,525               $35,650
              Renewal                 Core                                                                                                                                ;ew
                                     $417,850                                                                                                                           $417,850
              Approved/Unfunded                                                                                                CE for Physicians
                                                                                                                               Patient Problems
                                                                                                                               Nurse & AH CE                              New $
                                                                                                                                                                         $125, ow
                                                                                                                               $125,000


              New                    Core
                                     Supplement                                   Cancer Detection       Health Careers        Community Hosp.
                                                                                   Low Income Pop.       in Ohio -RCIO         Libraries
                                                                                                         (see Core supple)                                                New $
                                                                                  Toxicology Lab.                                                                      $196,852
                                       $25,000                                      $130,788                                    $41,064
              Developmental                                                                              Home Trng. in
              Component                                                                                  Hemodialysis                                                    New $
                                                                                                         $100,000                                                       $100,000
                   Total               $"2,850           $331,454                    $227,976            $120,525              $201,714                                li324,519
                      11  The Region requested in excess of its committed level of $445,825 which recently has been
                          reduced to around $400,000 due to RMPS fiscal constraints.






           Northwestern Ohio
           Regional Medical Programs          -6-              RM 00063    5/71


           multiphasic health screening,information/systems, dental diseases
           and RMP/CHP collaboration.


           Review Process: Project ideas,which are solicited periodically  from
                           the Region's health personnel, are first  submitted
           to the core staff and then to the appropriate reference panel for
           approval and assistance in development.   CHP also reviews for approval
           or disapproval of continuing the development of the proposal.  A cote
           staff member writes the proposal in accordance with RMP  guidelines
           and with the assistance of other appropriate core personnel and  CHP
           groups.  Endorsement of the proposal is obtained from the people,
           institutions, and reference panels. affected by it and is then submitted
           to the Executive Committee of the RAG. Upon  Executive  Committee
           approval, the proposal is submitted to the.total RAG.

        I. CONTINUATION WITH COMMITTED MONIES OF SIX ONGOING ACTIVITI ES

           The activities for which continuation support is requested are:

               Stroke Rehabilitation Training
               Uterine Cancer Control
               Itensive Nurse CCU Training
               Smoking and Health
               Dial Access
               Ottawa Valley Continuing Education Council  (Co-funded with Ohio State RMP)

           A breakout of these activities categorized by program priorities is on page 5
           of this summary.  Although the committed monies for these six activities
           were $445,825, the amount requested in the anniversary  application
           is $484,817. In addition, RNPS financial stringencies  have  reduced
           the commitment to around $400,000.

           During staff review of this application there were a number of
           unresolved problems which are noted as items of concern on pp.1-2
           of this summary. Because staff continues to have  serious  concerns
           regarding the management and viability of the Northwest Ohio RMP, it
           recommended that*:

               1.  The 02 operational year be extended for a six-month  period,
                   through December 31, 1971, at the Region's current rate 'of
                   expenditures, not to exceed an annualized level of  $702,924
                   (approximately $351,462 for six months) for the support  of
                   core and the six currently funded operational projects.

               2. The six-month extension period be used to conduct  a  site
                   visit which should be more in the nature of an ass stance
                   than a traditional visit, to serve the following  purposes:



           *Not yet (3/19/71) approved by Director.





           Northwestern Ohio
            Regional Medical Program             -7-                        RM  00063  5/71


                         a. Determine  the actual  progr6ss  which  has  been
                            made with  reference to  the  recommendations  of  the
                            May 1970 site  visitors  and  the  subsequent  Management
                            Assesnient Team.

                         b. Evaluate the capability  of  the  Region,  with  its  present
                            staff, to conduct its program.


        II. RENEWAL OF CORE SUPPORT  AND  HEALTH  CAREERS  CORE  SUPPLEMI?Nl'


                                                                              Requested
             Core:  I)tiring the May 1970 site visit, the following           Third Year
                    observations about the core staff were made:              $417,850 Renewal
                                                                              - 25,000 Supplemental
                1.  The program planner-evaluator and epidemiologist          $442,850 Total Core
                    who had been appointed  at  the  suggestion  of  the  April
                    1969 site visitors had little experience or background
                    to perform their required duties.

                2.  The three physicians  who  were  Chairmen  of  the  categorical
                    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.

                3.  Core staff functions were not well defined-and bore little
                    relation to position titles.

                4.  The Program Coordinator,  whom  the  site  visitors  believed  to
                    be  a  sincere,  devoted  and  dedicated  physician,  was  unsuccessful
                    in providing  the  required  leadership  to  the  Region.

             The subsequent  Management  Assessment  report  confirmed  the  site  team's
             gloomy findings, elaborated upon  the  causes  of  the  core  management
             embroglio, and sent  recommendations  for  their  solution  to  the  grantee
             organization for action.

             The present application (pp. 67-70) explains what steps have been
             taken to correct some 6f the deficiencies noted in the Management
             Assessment  Report.  The  areas  addressed  are:  low  staff  morale,
             inadequate core staff involvement in RMP activities, poor indoctrination
             of new employees,  shortcomings  in  core  input  into  financial  management,
             lack of regular  staff  meetings,  organizational  lines  of  authority,
             management documents,  interference  with  project  activity  by  core
             staff, control of time  cards,  purchasing  authority,  site  of  RAG
             meetings, distribution of reference panel meeting minutes, and reference
             panel membership.

             In an effort to tighten up  on  core  administration,  the  staff  has
             been reorganized.  Primary  changes  include  the  addition  of  an  Associate
             Coordinator for Administration, the creation of a full-time position
             for Deputy Program Coordinators, and the freeing of the Coordinator
             from administrative detail to enable  him  to  devote  more  time  to
             medical aspects of the program.  The application states that overall






            Northwestern Ohio
            Regional Medical Program          -8-                  RM  00063   5/71




            program direction by the Coordinator  and  Deputy  Program  Coordinator
            now proceeds in close liaison with the Executive  Board  of  the  RAG.

            In addition to renewal funds for continuation of core activities
            $25,000 is requested as NWORMP's  contribution  to  the  program
            Ifealth Careers in Ohio, to which three Ohio  RMPs  are  contributing.
            It is being conducted under the auspices of the  Ohio  State  RMP  and
            is centered in Columbus. Applications  in  the  current  review  cycle
            request funding for the next year for this program as follows:

                           Ohio State PM            $145,000
                           Northeast Ohio RMP         50,000
                           Northwest Ohio RMP         25,000
                                                    $220,000

            Ohio Valley RMP contributed $5,000 to this  activity  last  year,  but
            has since withdrawn its support.

            The NWORMP will re-evaluate the objectives  and  activities  of  this
            Health Careers Program before determining the type-and quantity
            of support beyond 1971.

       III. ACTIVATION OF TWO PREVIOUSLY APPROVED BUT UNFUNDED ACTIVITIES

            Project #14 - Continuing Education for Physicians. This            Requested
                           project is not described in the anniversary         First Year
            application.  June /July    1970 Committee/Council recommended      $75,000
            approval of $75,000 for a one-year  feasibility  study  (not  to
            be included as part of core)  which  combined  the  programmatic
            aspects of two separate but  similar  continuing  education  proposals
            which were presented for their review.  Essentially, the two proposals
            were for the implementation of  continuing  education  programs  based
            on needs identified by physicians  throughout  the  Region,  the
            identification of certain hospitals  as  learning  centers,  and
            the presentation of regional conferences and clinical programs.
            Approval was predicated onthe belief that  the  Region  was  beginning
            to make some sincere efforts in continuing  education  and  that  more
            planning time was needed to allow a coordination of its efforts.

            The region sees this activity as  contributing  toward  its  continuing
            education program priority.


             Project #17 - Patient Problem-Oriented Education Program           Requested
                           For Professional Nurses and Allied Health            First Year
             Personnel.  This project is not described in the anniversary        $50,000
             application.  June/July 1970 Committee and Council recommended two-
             year approval of this project as a feasibility study  not  to  be  in-
             cluded as part of core. It was thought  that  the  reduced  amount  of
             $50,000 per year would be sufficient funding.  The principal objective





             Northwestern Ohio
             Regional Medical Program              -9-              RM00063    5/71


             of this proposal is to help bring about a  regional  distribution
             of appropriate knowledge to all non-physician health personnel
             regarding current trends and changes in the concepts of  care  of
             patients with heart disease, cancer,  stroke,  or  related  diseases.
             Approval was recommended because it was though that  the  planned
             subregional committees and the  inter-professional  aspects  of  this
             activity might develop into this Region's first example  of  a  truly
             regionalized program.

             The Region sees this activity as contributing  toward  its  continuing
             education program priority.



         IV. INITIATION OF THREE NEW ACTIVITIES

             Project #20 - Detection of Cervical Cancer in a Low-Income          Requested
                           Pppulation with Adjunctive Teaching of                First Year
             Breast Self-Examination. This proposal is  for  the  continuation   $31,070
             and expansion of a cervical cancer detection program  started  in
             1967 under a USPHS grant at the Maumee Valley Hospital,  now  the
             Teaching Hospital of the Medical College of Ohio at Toledo.  The
             service presently is available not only at Maumee  Hospital,  but
             at migrant worker clinicsln four counties, the Planned Parenthood League
             of Toledo, and the Toledo Health  Department.  The  project  will  be
             expanded programmatically with the addition of  education  in  breast
             self-examination, and geographically with the extension  of  services
             to Toledo State Hospital and, hopefully, the  outlying  county  health
             departments of Northwest Ohio.

             Second Year:  $28,584                         Third   Year:   $31,070


             Project #21. - Northwestern Ohio Regional Toxicology  Laboratory.    Requested
                           Yhe-Toxioology Laboratory of the Medical College       First Year
             of Ohio at Toledo is proposing to function as a 24-hour-a-day         $99,718
             regional toxicology laboratory to provide analytic toxicology
             service to other medical institutions in the  region,as  follows:

                1.  Perform assays on specimens submitted by any  hospital  in
                    the Region for drug/chemical poisoning 24 hours daily.

                2.  Assist coroner's office in determining the nature and
                    cause of death in suspected drug abuse cases.

                3.  Provide service for monitoring durgs in the urine for
                    various drug addict rehabilitation programs.

                4.  Provide analysis and indentification  of  confiscated  illicit
                    drugs for area law enforcement agencies.

             Second Year:  $90,023                         Third   Year:   $80,665







            Northwestern Ohio
            ReIgional Medical Program                              RM 00063  5/71
                                               -10-


            Project #22 - Proposal for Improving LibraKy Services.      Requested
                          In this project,, under the auspices 'of      First Year
            the Medical College of Ohio at Toledo, a consultant          $41,064
            will survey each hospital in the Northwest Ohio Region to
            1) determine the needs and potentials of the hospital libraries,
            2) suggest ways to enlarge or establish 4 collection, extend
            library services, and train personnel, and 3) obtain a commitment
            from each hospital to support and maintain a library4  People
            will be recruited and trained or retrained to serve as hospital
            librarians where there is a need.  Several methods will be used
            in the training program, including on-the-job training, work-training
            in another library, and one-day seminars.  Once the program
            is established, a librarian will travel, instruct, evaluate, and
            maintain the training program.
            Second Year:  $30,974                       Third Year:  $30,117


         V. DEVELOPMENTAL COMPONENT                                        Requested
                                                                           First Year.
            The entire amount of the requested developmental component     $100, 00
            would be used to support a training program for home dialysis at
            the Hospital of the Medical College of Ohio at Toledo.
            This program is described by the Region as a first step in the
            development of a tri-regional renal disease program on pp. 36-43
            of the application.








                                                             GRB/RMPS
                                                             3/22/ 71




                                                                                                                                              Nort@i%,;c-@tern 0
                                                                                                                                              LL@@@O  @3   -5LZ
                                                                                                                                                              -1
                                                                                                                                               (A-,iniversary    Review)
                                                                                                       03






                                                                                                                                     ioo,coo         18     460       118,460
               @Developmental**                                                                                   1 o@qo

                                                                                                                                                                            1-32
               CORE                                                          417.850*                                                4'@ 7,.@@__     217,282

                                                                                                                                                                       25,
               ,qbre  Supplement                                                                                   25,000*       i   25,000
                                                                                                                                                                            _900
               irl Stroke Rehab. Training                       101,425                                                              1011425         3 @8  1         138,Ll@_
               .4'-2 Uterirte Cancer Control                 97,188                                                                  97,188          21,741           1182929
                                 Care
                   Nurse Training                              187.,379                                                              187,379         71,887           '@)591266@
               "r6 Smokin- & Health                          35,650                                                                  35i650          10-485           46,-,-35

                                                                                                                                     42,650          6,832            4
               #7  D4-al Access                              42)650                                                                                                        9,489

                                                                                                                                                     5,343
               .vl5 Continuing       4edical Ed.-            20,525                                                                  20,525                           25,863
               @#14   CE for Physicians
                                                                                               $75,000                               75,000          263,000          101.%OGO
               -#'x'O Cancer Detection in
                                                                                                                                                     14Lo22           45,760
                    Loi-7-Income@pp,.qlation                                                                     3 1,OZ_q            312070
               .#21 Toxicology Laborato@.;
                                                                                                                 92@718              99,718            909-           129,627

               #22 Co=.  Hospital Libraries!;
                                                                                                                 41.C!64             _._@.l@Q64      04@3q.__.,       51.497
               #17 Patient Ptoblems-illurse
                                                                                                      no
                   Continuin;z Education                                                        50,0                                 50,000
                                                                                                                                                 @l@l 4@              6l.lG4






                                        '!'u"A            $401@,,   817    $4@,850           $125,000          296,852                1,324,519 4810107              @1,805,62-0
                                         Per Joseph      Jeiiel I



                                                                                                         CYCLV         M 00063 5/71
                                                                                     04          PEI@:CD
                                                     BREA:KOUT OF REQUES@'



                                             i CO':\T @U7!@-G
                                                                            p@REVIOUSy
          '-D-@@TIFICATIO',\' OF                                                                            ID)IRWCT                      TOTAL
                                             :ACTIVITIES     rEi\'E@qAL    @APPr,/UNFU\.    AC-.IVITIES@                :IIN'DIRECT  It

            Developmental


            CORE


          i Core Supplement




            #2


            #4


            #6



                                                                                                               21,250          6,375         27 625
            -lil 5                               21,250



                                                                                                28,584         28,584       13,397.
            #'20
                                                                                                                                            121,702
                                                                                                90,.023        90,023         31,679

                                                                                                                                                 932
                                                                                                30,974         30,974            958         41@
             2 2









                                                                                                                                           233,240
                                                                                                 149,581        170,831       62,409
                                 TOTAL             21,250
                                                                                @,ph Jewell   aid ',4r. Keller (N.W.O.RMP) 2
                                                               versation,@
                     Requested  for  2  years   only   par   edIn







                                                                                     05






    !Velop@,ental
                                                                                                                                    100, coo

                                                                                                                                    41.7,850

     e  Supplement
                                                                                                                                    25,000

                                                                                                                                    ioii,425

                                                                                                                                    97,188       118,929

                                                                                                                                    '@37,379     259,26--@
                                                                                                    ----- - ----

                                                                                                                                          -50     46,
                                                                                                                                    35,0


                                                                                                                                    42,650        4c,,'-82

    5
                                                                                                                                    41    775     53,49'@

                                                                                                                                    75,000        C-

                                                                                      @Al_,-970___!.__.14,690     45,760            90,724       13@,50--'

                                                                                                     33,.@74     114,               270,',,06   365,363

                                                                       39,
                                                                                                                                      10@,155
                                                                                                         397        1
                                                                                                                  4 514


                                                                                                                                    50  000
                                                                                                                                                 61,-'64-






                                                                    141,8'j2         141,852       51),661      201,513      1,6373,202      2)240,-@'79




                                                                 (A Privileged Co-Lumunication)




                           SUMMARY OF   REVIEW  AND CONCLUSION OF
                                APRIL 1971 REVIEW COMMITTEE


                        NORTHWESTERN OHIO REGIONAL MEDICA.1, PROGRAM
                                       RM 00063 5/71


                      FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL


             RECOM4ENDATION:  That additional monies be provided for one additional
                                year of'operation.

             Contin6ation Commitment

                     Year                        Request                     Recommendation

                      03                        $484,817                       $391,764
                      04                            21,250                         -0-
                      05                            -0-                            -0-
                         Total                  $506,067                       $391   764


             Renewal  of Core

                     Year                        Request                     Recommendation

                      03                        $417,850                       $295,540
                      04                                                           @0-
                      05                           -0-                             -0-
                         Total                  $417,850                          295,540

             Supplemental F     in

                     Year                        Requ6st                     Recommendation

                      03                        $421,852                           -0-
                      04                         149,581                           -0-
                      05                        l@41   5@2                         -0-
                         Total                  $71j,285                           -0-

             Total AftniversarV Request

                     Year                             e,,t                   Recommendation

                      03                       $1,324,51.9                     $687,304
                      04                         170,831                           -0-
                      05                         141@852                           -0-

                         Total                  $1,615,952                     $687,304 Maxiintim




            Northwestern Oli io                    -2-               RM  00063  5/71

            Critique:  The Committee  reviewers recalled  the reports of  the  May  1970
                        site visitors and the subsequent  management  assessment   team.
            which raised multiple serious questions about the organization and
            management of the NWO@IP.  The  present  application  indicates  that  the
            Region has taken steps to correct the identified deficiencies, but the,
            Committee, along with recent staff reviewers, was uncertain of the success
            of the changes which have been made.  The following specific pro@16ms,
            were described as illustrations of areas of concern:

                 1. Lack of information as to  the  capabilities  of  the  new  Deputy
            Program Coordinator and  the  New  Associate  Coordinat6r.for  Administration
            and their@respective roles -  particularly  their  relationships  to  the
            Coordinator.  For instance, under the new organization it appears t at
            everything within cote staff flows through  the  Deputy  Coordinator  to  the
            Coordinator. The written  rationale  behind  the  reorganization  was  the
            freeing up of time for the Coordinator to pursue further relationships
            with the physicians in  the  Region.  The  Committee  reviewers,  however,
            believe the entire organization and functional structure should be
            scrutinized, especially with regard to the desirability of using
            internal reorganization as a  method  of  circumventing  a  Coordinator's
            administrative shortcomings.

                 2.  The attendance of all regular staff meetings of the RAG Chairman
            and  the President of the Medical College  raises  questions  as  to  their
            precise roles in the administrative  structure  of  the  organization,  as
            Opposed to the policy-making structure.

                 3. Concern was expressed  about  the.limited  consumer  input  on  both
            the  RAG and its Exeuctive  Committee.  Further,  the  relationship  o  .
            the Executive Committee to both the RAG and the Core staff was questioned---
            it was unclear to the reviewers which  group  had  authority  for  which
            decisions.-

                 4. One of the concerns of  early  site  visitors  was  the  relative
            tblb, or lack of role, of the Medical College.  Since all three new proposals
            and developmental component activities are  based  at  the  Medical  Cbllege,
            reviewers wondered whether perhaps the pendulum has swung in a new
            direction and whether perhaps the Medical College  is  using  RMP  to  mount
            .basic programs for the school itself.

                 5. The fragmentation of the  State  among  the  Northeast  Ohio,  North-
                       I
            West Ohio, and Ohio State Regional Medica  Programs.

            It was thought that before any decision  could  be  made  regarding  the
            ultimate future of this Region, a site vigit team would have to deter-
            mine the actual progress which has been made in the administrative and
            organizational realignment and the capability  of  the  Region,  with  its
            present staff, to conduct its program.  As  with  the  Northeast  Ohio  RMP,
            the reviewers essentially were questioning  whether  this  is  indeed  aviable
            region.  And in view of this underlying question, the staff concerns listed on
            pages one and two of the yellow  summary  and  tne  apparent  fundamental
            administrative deficits, the consensus was  that  the.NT40RMP  should  be




            Northwestern Ohio                       -3-                    63  5/71
                                                                    ym 000

            supported for one additional  year at its current rate'of expenditures,'
            not to exceed a level of $687.304, with similar holding actions being
            taken for the Northeast Ohio  and the Ohio State lOlPs. Each of  the  three
            Regions should receive a site visit to concentrate on that  I DroRram's
            problems, strengths, and weaknesses.  After  these  three  information-
            gathering visits, a s6cond-stage consultative visit should  include  the  RAG
            cbdirm6n, Coordinators,, sponsoring institution represen tatives,  'and
            other officials of each program to discuss amalgamation  of  the  programs.
            The one year continuation of the three separate RMPS,  then,  is  viewe
            by the Review Committee only as an interim step toward the unification
            of Ohio.

            CONTINUATION WITH CO@n4ITTED FUNDS OF SIX ONGOING ACTIVITIES

            Continuation funds were requested  for the following activities:

                   Stroke Rehabilitation Traini@
                   Uterine Cancer-Control
                   Intensive Nurse CCU Training
                   Sraokin3z and Health
                   Dial Access
                   Ottawa Valley CE Council

            The Review Committee agreed that continuation funds should be provided
            for one additional year, calculated on the current  rate  of  expenditures.

            RENE WAL-OF CORE SUPPORT

            The Committee consensus was that core should be renewed  for  one  additional
            year, the actual amount to be calculated on the current rate of expenditures.

            SUPPLEMENTAL FUNDING

            Supplemental funding was requested for the following:
            A.  Supplemental core support for NWORMPts contribution to the program
            Health Careers in Ohio.  In view of the staff opinion that expansion of
            this program exceeds the bounds of permissible RMPS support, the Review
            Committee recommended disapproval of supplemental monies for its
            expansion.
            B.  Activation of two previously approved but unfunded activities:  Continuing
            Education for Physicians and Patient Problem-Otiented Education ProRtam for
            Professional Nurses and Allied Health  Personnel.  Although  no  additional
                              . d
            funds were recommen ed for the initiation of these activities, the Region
            is not prohibited from exercising its rebudgeting authority for t 6ir
            conduct.

            C4 Initiation of three new activities:  Detection  of  Cervical  Cancer  with
            Ad@iunctive T66chinR of Breast Self-Examinatibn, Northwestern  Ohio  ReRional
            Toxicol6gV LaboratoEy, and Proposal for Improving Library Services.





                                                                    RM 00063 5/71
          -Northwestern Ohio                       -4-
          C6nsider?ng the numerous and serious problems which the NWORMP is
          experiencing, the Review Committee could recommend no additooal funds for
          the initiation of these new projects.  The Region is not prohibited,
          however, from beginning the activities with r6budgeting funds, if it
          chooses.
          D.  A developmental  omponenit-.  The designation of the entire'amoliht of
          the.developmental component for a renal dialysis effort raised
          questions for the Committee as to the Region's understanding of the
          potential uses of such monies and the Regional decision-making process.
          The recommendation was for disapproval of developmental funding.










                                                RMPS /GRB /4/21/71







                                 REGIONAL MEDICAL PROGRAMS SERVICE
                    S    Y OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION
                                     (A Privileged Communication)


            OHIO STATE REGIONAL MEDICAL PROGRAM                   RM 00022 5/71
            1480 West Lane Avenue                                 April 1971 Review Committee
            Columbus, Ohio 43221

            Program Coordinator:  William G. Pace, III, M.D.
            This Region presently is funded for its 02 operational year at a direct
            cost figure of $973,793, which includes carryover of $60,589.  During  this
            period the Region received indirect costs of $182,037 which  represents  an
            overall indirect cost rate of approximately 19%.  The current budget period
            ends June 30, 1971.  This application requests support for:

                1.  A developmental Compon6nt
               II.  Continuation with committed support of core and two ongoing Activities.
              Ill.  The renewal of three activities.
               IV.  The activation of three Council-approved but  unfunded  activities,
                    and expansion of core.
                V.  The implementation of nine new activities.
               VI.  Termination of two activities.

            The Region requests $1,832,1892 direct costs for its third year of operation,
            $1,871,877 for the fourth, and $1,728,866 for the fifth year.   A  breakout
            chart identifying the components for each of the 3 years is  included  as
            pages 15 through 17 of this summary.
            No site visit is planned to the Ohio State RMP. However,  staff  review  of
            the continuation request identified certain areas of concern in  which  the
            Cormittee and Council may be interested.  These are listed briefly below
            and ate discussed in mor6 detail on page 8 of this summary.

              1. The dearth of minority group representation on core,  RAG,  and  the
            entire regional committee structure, as well as the  Region's  fulfilling
            the RAG requirement for members of the public with individuals  not  parti-
            cularly representative of the general public (e.g. University Vice President).
            2) The possibility that the RAG and core staff are  contributing  to  the
            institutionalization of the RMP and thereby losing flexibility  in  dealing
            with emerging problems, And the affect on program direction of the grantee
            institution, Ohio State University.
            3)  The lack of allied health competencies on core staff
            4)  The role an d effectiveness of the Local Planning Committees.
            5)  The extent to which the activities of this region affect  the  delivery
            and organization of health services.
            6)  The extent and types of cooperative relationships which have been
            developed.





           Ohio State Regional Medical Program        -2-                RM 00022 5/71
           7)  Inter-regional cooperation among the four RMPs in Ohio

                                           FINDING HISTORY

                                           Planning Stage
           Grant Year                      Period                  Funded (direct costs)

           01                       4/67-6/68 (15 months)'                $140,271
           02                       7/68-6/69                              920,962

                                         Operational Program
                                                   Funded                     Future
           Grant Year        Period              (direct dostsi             Commitment

           01            5/69-6/70 (14 months)      $1,226,971 I/
           02            7/70-6/71                     973,793 I/               --
           03            7/71-6/72                      --                 $642,667 2/
           04            7/72-6/73                                            642,667

           I/ included carryover
              reduced from previous commitment of $714,075  because  of  RMPS  fiscal
              constraints

           GEOGRAPHY AND DEMOGRAPHY The boundaries of  the  Ohio  State  Regional  Me dical
                                      Program have remained constant since the Region'  s
           planning stage and include 61 counties in central and southern Ohio.
           Columbus is the geographic and cultural center of this area.  Surrounding
           regions in Ohio are Northeastern Ohio RMP (Cleveland), Northwestern Ohio RMP
           (Toledo) and Ohio Valley RMP (Cincinnati  and  parts  of  Kentucky).  The
           Region contains the Ohio State University  Medical  School  at  Columbus;
           14 nursing schools; one physical therapy'-two cytotechnology, four
           med ical technology and eight radiologic technology facilities.  The Region's
           127 short-term non-federal hospitals  contain  approximately  17,000  beds.
           There is, in addition, a diagnostic, service  and  teaching  cancer  clinic
           -in Columbus.

           HISTORY.:  After two revisions of its original planning grant application
                      tu provide clarification and evidence of regional participation,
           program leadership, RAG status and other  considerations,  the  Ohio  State
           Regional Medical Program received a small planning  award  in  April  1967.
           The interim Program Coordinator (Dr. Richard  Meiling)  was  replaced  by
           Dr. Neil C. Andrews in November of that  year.  The  second  year  planning
           grant, of a considerably larger magnitude, included funds for core expansion,
           and four feasibility studies (one being earmarked  monies  for  a  mobile
           coronary care unit study).
           A pre-operational site visit to the Ohio State  RMP  was  conducted  in
           December 1968.  Although there were unanswerable questions about the
           program, since it was still in the developing  stage,  the  site  visitors
           (and subsequent Committee and Council  reviewers)  agreed  that  sufficient






           Ohio State Regional Medical Program       -3-                 RM 00022  5/71
           progress had been made to justify an  operational  award.  Peripheral  and
           local involvement of health personnel appeared to be proceeding well.
           The Local Planning Committee structure was considered particularly laudatory.
           The program was not as university dominated as had been expected  and  the
           quality of the core staff was thought to be good. The  major  concern  about
           the Region was that the Regional Advisory Group had not yet  become  active.
           It had not developed an overall program plan or  regional  priorities  and
           it had not involved the area's significant black population.  An 01
           operational award was granted for the support of core and 7 projects.
           Since that time, there has been no program site visit to this Region, and
           Committee, Council and staff have kept track of the Ohio State RNP
           primarily through review of its project  applications.  Some  programmatic
           considerations which have arisen in the various reviews are:

            1.  Questions of the extent and quality of cooperation among the four
           Ohio RNPS.

            2. The actual merits of the area continuing education  councils  which  are
           proposed for initiation' throughout the Region.(In the present  application,
           continuation support is requested for one, renewal  support  for  another,
           and new money for still a third which has been approved but rema ns
           unfunded--a fourth CE council proposal has been disapproved  by  Committee
           and Council on the grounds that evidence of the effectiveness of the
           approach was needed.5
            3. Although during 1970 the RAG seemed to have  become  more  active  and
           had formulated at least general plans for the Region, it remains wea     n
           consumer and minority group representation.
                In the fall of 1970, Committee and Council reviewers remarked on the
           fact that of the last 13 project proposals submitted by the  Region,  only
           three had emerged from national review with recommendations  of  approval,
           and two of these were renewals. It was thought that this  record  did  not
           reflect well on the local review process.
           The current coordinator,'Dr. William Pace, has been on board since February 1970.
           The Ohio State Regional Medical Program now is completing its 02 operational
           year.  The current funding situation.is summarized  on@the next page.






            Ohio State Regional Medical Program       -4-                  RM  00022  5/71

                              SUMMARY OF OPERATIONAL PROJECTS CURRENTLY
                                   BEING SUPPORTED BY-OHIO  STATE RMP



            Project Number and Title                  Future Years of     Funded (d.c.)
                                                      Commit. Support       7/l/70-6/30/71


            Core                                               2              $533,245

            #2 -.Coronary Care Unit Education                  1              55,572

                 Stroke Rehabilitation Training
                 for Health Professionals                      0              33,952

            #4 - Careers in the Health Service Program         0              25,400

            Yf6 - Mobile Coronary Care Unit                    0               107,623

            Yt8R- Computer-Assisted Instrtction                2               160$000

            #II- Council for Continuing Education:
                 Springfield                                   0              37,171

            #22- Council for Continuing Education:
                 Ottawa                                        2-             20,830

                                   Total                                      $973,793

            REGIONAL ADVISORY GROUP  In November of 1970 the Regional Advisory Committee
                                      of the OS/RMP adopted new by-laws and procedures
            which define thelfunctiong-@of the RAG:

                1.  identification of health care needs and problems
                2.  establishment of priorities for their solution
                3.  periodic revision of program direction as needs and priorities change
            Also, at the time, a nominating committee was  established  to  diversify  RAG
            representation.  There currently are 34 RAG members, of which one is black,
            but the by-laws provide for 45 members and a  slate  of  candiates  apparently
            now is being prepared.

            PROGRAM DEVELOPMENT AND REVIEW PROCESS  During the pre-planning stages of
                                                     project development, core staff
            works closely with the sponsors of each particular proposal in defining
            the need, determining the relationship to OS/RMP program goals, and
            available sources of support, and finally in the  actual  development  of  the
            project proposal.  Each final application receives review and comment by
            the appropriate technical review committee 6r,.-task force, as well as CHP..Xb)
            agencies, before being sent on to the Review Committee      (two or  three






           bhio State Regional Medical Program       -5-                  RM 00022 5/71
           RAG members assigned by the Program Coordinator plus the technical. committee).
           There currently ate five standing task forces:  Heart,  Cancer,  Stroke,
           Kidney, and Hospital Services.

           The Review Committee consideration of each proposal is the first  point  in
           the review process at which a decision regarding further progress  can  be
           made. All prior staff and task forte review is advisory  only,  but  the
           Review Committee decides whether to forward a proposal to the RAG (although
           there is an appeals procedure for the sponsor).  The RAG is the final
           decision-making body.

           REGIONAL NEEDS AND PRIORITIES In November 1970i the  RAG  reconsidered  its
                                           previously adopted (1968) general  goals
           and recast them in a more specific framework of needs and priorities.  The
           four identified categories of need and ptioriti6s within them  are  stated
           below:


           A.   Education

                1. That knowledge regarding the treatment of heart,  cancer,  stroke,
                kidney, and related diseases should be maximally kncK4n by the health
                professional within the region.
                2. That knowledge regarding appropriate personal care and  seeking  of
                treatment for symptoms of heart, cancer, stroke, kidney and  related
                diseases should be maximally known by the public within the  region.

           B.   Health Care Resources - Manpower

                1.  That adequate manpower in all health care categories be recruited.
                2. That health care manpower be distributed to  maximize  excellent
                health within the reg on.
                3. That health manpower categorie6,be developed which best  meet  the
                needs of the region.

           C.   Categorical Disease Programs

                1. That as far as possible there should be the elimination  of  heart,
                cancer, stroke, kidney and related diseases.
                2.  That as far as possible those with the sequellae of heart disease,
                cancer, stroke, kidney and related disease be rehabilitated to  the
                maximum physical, psychological, medical, and social level of functioning.

           D.   Resource Coordination and Assistance

                1. That the various regional health care resources  coordinate  their
                activities in a manner to maximize their effectiveness.
                2. That assistance be available to health care resources  to  enable
                them to develop eventually self-supporting programs that  actomplish
                other objectives of the OSIVQ.






                                                        -6-               RM  00022   /71
             Ohio State Regional Medical Program                                   5
             These are elaborated upon on pp. 35-37 and 46-88 of the application.  A
             chart showing the 03 year request as it relates to the stated regional
             needs is included as page 8 of this summary.
             CORE The core staff was reorganized in October 1970, at which time a
                   Division of Community Relations was created and  given  responsibility
             for subregionalization.  The primary vehicle for subregionalization is the
             eleven Local Planning Committees (recently reduced from 14 to more closely
             approximate CHP B agency boundaries) which vary in size from five to 32
             members each.  The responsibilities of the Local Planning Committees are
             stated to be the assessment of resources, the identification of problems,
             the establishment of goals, and the recommendation of action to the RAG.
             The new Division of Community Relations will work to strengthen these
             local groups, engage in project monitoring activities and  carry  out
             public 'relations and information functions.
             The reorganization also created a Planning and Evaluation Unit which will
             serve to involve core staff more in the evaluation activities of  individual
             projects.  this Unit also will seek to determine the effectiveness of the
             Region's resource allocations and will initiate a data and information system.
             The current core staff roster includes 17 professional positions (ail but
             3 full-time) and one vacancy.
             For a description of the areas in which funds are requested for expansion
             of core, see-oagelb@of this summary.
                                   COMPONENTS OF PRESENT APPLICATION
             DEVELOPMENTAL COMPONENT  The application states that                Requested
                                      developmental funds will be used           First Year
             to conduct special studies, short-term pilot activities, or         $97,379
             special research projects"consistent with the Regiongs  goals.
             Each proposal for use of developmental monies will be required to   complete
             the regular regional review procedures.  The first year request is slightly
             in excess of that allowable, and the subsequent two years are based  on  the
             total requests for those years contained in this  application.
                  Second Year:'.@183,289             Third  @ear:  $187,187
             CONTINUATION REQUEST- The Region is requesting the continuation at the
                                   committed level of core activities and two ongoing
             Projects:  #8R - Co=uter-Assisted Instruction, and #22 - Ottawa Valiley
             Continuing Educati           (joint y funded with NW Ohio RMP).  The
             application requests a comm tment of $714,075, although the Region recently
             has been informed that the amount will be reduced to $642,667 because of
             WS fiscal constraints.  Staff reviewers have recommended that the new
             reduced amount be awarded, but at the same time identified Areas of concern
             in which the Committee and Council might be interested.
             1.  Although the 1968 site team had suggested to the Region that the area's.@
             'black population be involved, two years later the number of minority





           Ohio State Regional Medical Program       -7-                  RM 00022  5/71

           representatives on core staff, the RAG, and the  entire regional committee
           structure is insignificant.  Further, the RAG representatives who are
           designated as members of the public appear to have been included  by  virtue
           of their professional and public ima es, and not because they  are  repr esenta-
                                              . 9
           tive of the general consumer public.

           2. Staff wondered whether this RMP might not  be  becoming  institutionalized
           through the apparent unwillingness of core staff and the RAG to adapt to
           new situations.  Staff also observed that the Region might show a greater
           response to community needs if the RMP were incorporated and  separated  from
           the present grantee institution, Ohio State University.

           3.  The lack of allied health personnel on the core staff was noted.

           14. If was difficult to determine the role of the Local  Planning  Committees.
           How do they relate to other-community planning groups?  What  activities  have
           bubbled up from these local committees?  Are t ey inc u     in t  e  orma
           regional review process?

           5.  What impact does this Region hope to have on the organization and delivery
           of health services, and does its activities reflect the right  approac  .
           There ate no indications, for instance, that the Region has  investigated  the
           health needs of the Model Cities areas or what it might do in the development
           of viable health programs in such areas.

           6. It was impossible for staff to determine the  extent  of  cooperative
           relationships which had been developed within the  Region.  Although  numerous
           Forms 9 (Core Cooperative Relationships with Other  Organizations)  were
           submitted as pp. 107-139 of the application, for the most part  they  reflect
           only the organizational affiliations of RAG members. Staff  could  not  tell
           whether the Region misunderstood the purpose of the forms or  whether  there
           were few joint undertakings to report.

           7. The extent of joint participation and cooperation  among  the  several
           Ohio Regional Medical Progra-n is open to question;

           Despite the ahove questions, the consensus was that the Region should be
           supported at its committed level. The recent  core  reorganization  provides
           for a Planning and Evaluation Unit as well as a Community Relations Division.
           Although it is still too early to measure the quality of evaluation activities,
           the Regionis growing awareness of the necessity for evaluation  is  reflected
           in this reorganization.  The Community Relations Division should do much
           toward helping the Local Planning Committees hone in  on  community  problems
           and devise solutions, and there are indications of a  developing  relationship
           with CHP. Further, there is evidence of core's emphasis  on  functioning  as
           a catalytic agent. The RAG is still in transition, but appears  to  be  moving
           into a firmet decision-making role with the identification of  RAG  functions
           and a new interest in formulating a workable  regional  plan.  Hopefully,
           there will be a concomitant move away from OSU dominance.





















                                                                                                 PROGELAM AREA                                                                                   AR
                                                                                                         HEALTH MANPCWEP
                                                    ADMINISTRATIOL
                    O%GOIII"C- COHP(                 Core                                                 Health Careerp
                                                                                                           Ohio
                           (co=itte                  ($533,550)                                           (funded througl
                                                                                                                                  cu Triui.g
                        Renewal                                             Tri-CountY  I                                        Stroke Rehab.
                                                                            ($40,049)
                         (new.$)
                                                                                                          oluntedr Health         Phonccardiosca
                                                    ore Expansion            G-eater   Po                 Services                 Scrccnir-S
                                                                             CE   Council
                                                                                                                                                                                        ew
                                                                                                                                   ($62,400)                                            0,@146
                        (new                        $450,870)
                                                                                                                                           ontrol
                                                                                        rion                                                 ',ephrol
                      P-(" C--ED  CO,                                                   cial Scrviceq
                                                                                                                                                                                    $359,224


                                                                                                                                                             ($ 37 966)
                        (r.ew                                                                                                                                                      $1,735.513
                       subtotal                     @984,420                     $273,960                 $15,900                    $423,,                   $37,966
                                                                                                                                                                                       97 .37 9 2

                        Development
                      Co,irer@ent

                      Total
                             I,' Recently reduced to $642,667
                       21 Developmental comonent request is     $6,000 in excess of the allowable 10% of 02 year level





           Ohio State Regional Medical Program      19-             RM 00022  5/71

                AL RGQUEST

           PROGRAM AREA: CONTINUING EDUCATION
           Project #11R - Tri-County Continuing Education Council        3rd Year  $40,049
                          Support is requested for the third, fourth and
           fifth years of this activity,, after which time it should be totally self-
           supporting.  The goal of the project is the provision of continuing education
           programs to local health professionals of Champaign, Clark,  and  Logan
           counties to enable them to deliver the best possible care.  A 32-member
           council functions, for the most part, with and through other organizations
           and agencies, serving as coordinator, catalyst, liaison, clearinghouse,
           and resource center, as well as an occasional source of money  to  help
           launch continuing education activities. Local funds  on  a  shared-cost
           basis are required for most activities.  Local acceptance of the council
           has openedfithe possibility of its expanding to include two  additional
           counties.  It is hoped that a professional library source can be developed.

              4th year:  $39,774                     5th year:  $39,688

           PROGRAM AREA: CATEGORICAL DIS@ES

           Project #2R - Coronary Care Unit Training                 3rd Year  $48,050
                         The first two years of this activity conct%trated
           on the actual training of nurses in CCU techniques, but the  final  two
           years, for which renewal support is.being requested, will be concerned primarily
           with assisting hospitals in developtdg self-supported CCU training programs.
           Cote area classes will be continued, however, on a selective  basis  and
           co-sponsorship for the courses sought from local organizations,  ut t ese
           classes will decrease as hospital i@,service training increases.
           4th year  $48,800                             5th year -.0-
           Project #3R - Stroke Rehabilitation Training                3rd year  $33,969
                         A third And final year of funding is requested for
           this community-based program of education in stroke management.  During
           the coming ytat, emphasis will be placed on evaluation, distribution
           of information about the program and providing consultation to other
          'communities interested in developing similar programs.

       IV.  APPROVED/UNFUNDED ACTIVITIES FOR WHICH NEW MONEY IS REQUESTED
           Supplemental money is requested for the activation of  three  activities
           and *i expansion of core which have received previous  Council  approval
           but for which funds have not been included in the grant to t e  Reg  on.






            Ohio State Regional Medical Program       -10-                    RM 00022 5/71

            Core Expansion  Juiie/July 1970 Committee/Council         3rd Year      $450,870
                              recommended approvalfoi three years of
            supplemental funding ($533,245, $598)286 & $666,694) for a general and
            non-sp6cific'expansion of core staff and activities.
            The additional monies which are requested for core expansion would be
            distributed as follows:

                   Administration                         '$  190,000
                   Manpower                                   110)000
                   Categorical Diseases                       63,585
                   Coordination of community resources        504000
                   Inter-regional coordination                37,285

            $110,000 is requested to supplement the $35,000 of      committed  monies   for
            the program Health Careers in Ohio (HCIO).  Initiated in March of 1970
            and centered  in  Columbus,  this  activity  represents  a  cooperative  venture
            among three RNPs in Ohio, and each is contributing funds to the OS/RHP
            for its support.  Ohio  Valley  RMP  contributed  $5,000  last  year,  but  has
            since withdrawn support.  The applications in-house request the following
            for Hi3IO for the coming year:

                     Ohio State RHP                    $145,000
                     N.E. Ohio R.MP                      50,000
                     N.W. Ohio RMP                       25,000
                                                   @220@    000

            The $37,285  for  inter-regional  coordination  probably  is  for  the  addition
            to core of  a  staff  person  responsible  for  facilitating  communication  and
            cooperation among the Ohio Regions.

            Beyond tht" two items,  further  specifications  as  to  the  use  of  the  core
            supplement is not included in the application.
                4th year:  $470,000                   5th Year:  $485,000'

            PROGRAM AREA: CONTINUING EDUCATION

            Project #14 - Greater Portsmouth Area Continuing Education             Requested
                           Council - Implementation of this project would          First Year
            bring to a total of three the subregional continuing                    $10,976
            education councils in this Region.  The other two are the
            Ott,awa Valley and the Tri-County Councils.  The Greater Portsmouth
            Area Council would create a mechanism for planning, development and
            implementation of a cohesive program of educational activities for members
            of the health  professions  in  five  rural  counties  in  southern  Ohio.  The
            July 1969 Review Cormnittee felt it could not recommend funds for yet
            another council of this sort in the absence of evaluative and experiential
            data  from  those  ongoing.  August  1969  Council,  although  recognizing  the
            Cominittee's concerns, recommended approval As requested and suggested the
            Region be advised of the necessity for the car6ful planning and development





             Ohio State Regional Medical Program                              RM 00022 5/71
             of such projects as an approach to improving health care delivery in
             communities away from a medical center.
                2nd year:  $11,399                 3rd year:  $11,844

             PROGRAM AREA: HEALTH MANPOWER
             Project #26 - Program to Improve Volunteer Services               Requested
                          Using several hospitals as demonstration             First Year
             base institutions (six to ten), this project hopes to            $15,900
             develop new and productive ways of using volunteers in   community
             health care and evaluate the emerging role of voluntarism in the health
             field.  November 1570 Committee/Council in reviewing this request believed
             the improvement of patient care through the use of volunteers to be of
             questionable value. Consequently, additional funding for the  conduct  of
             this project was not recommended, although the Region@-was not precluded
             from initiating it through rebudgeting.
                2nd year:  $16,852                   3rd year:  $17,899

             PROGRAM AREA: CATEGORICAL DISEASES
             Project #15 - Central Ohio Phonocardiocan Sc   in              Requested
                          The goal of this project is to provide             First Year
             heart-sound screening for 150,000 children in 47 counties        $62,400
             and to establish this program as apermanent Oart of  school  health
             examinations.  December 1969 Commi@e/C un  1  -)ieved this proposal
                                                    o  ci' be
             represented an acceptable, inexpensive, and efficient approach  to
             screening for heart disease in children, and recommended approval in  the
             amount requested.
                 2nd Year:  $63,300                    3rd year-.  $64,@oo

         V. NEW  ACTIVITIES

             PROGRAM_AREA: CONTINUING EDUCATION
             Project #31 - Development of POMR System in a Community           Requested
                          Hospital - A medical records system will be          First Year
             established in the Marion General Hospital to provide A           $32,410
             more relevant and complete medical data base upon which to
             implement comprehensive health care for patients.  The  operating
             schedule calls for three year-long phases: Phase I  for  training,
             development and initial evaluation; Phase II involving interregional
             computer linkage with the Vermont Medical Center; and Phase III for
             full-scale operation.  Some core funding and staff expertise and Marion
             General Hospital funding already has been invested, and this project  is,
             in fact, in its initial phase.
                   2nd.year:  $46,321              3rd year:  $46,321






            Ohio State Regi onal Medical Prpgram        -12-                   RM  00022  5/71

                         - Training Program
            Project #33                       for  Medical  Social   Service          Rdqueste@
                           Personnel  in  Hospital  Settings  -   Short-term       -First Year
            in-service education and training programs will be developed              $10,000
            for those individuals who have-been assigned medical social
            service responsibilities in hospitals, extended care facilities,
            and home health  programs.  The  program  will  encourage  the  use  by  patients
            and their  families  of  available  local  and  regional  health,  welfare,
            rehabilitation, education and other resources.  It is anticipated that
            after  the  program  is  established,  participating  hospitals  will  incorporate
            medical social services into their overall programs.
                2nd year:  $10,480                       3rd year:  $10,984

            PROGRAM AREA: CATEGORICAL DISEASES

            Project #34 - Cancer   Management Evaluation     The   purpose       Requested
                           of this project is to define cancer                   First   Year
            management problems in the Region and develop and recommend             $29,@98
            programs  for  their  solution  to  responsible  and  interested
            individuals in each county.  Evaluation of responses to suggested
            areas for improvement in each.,--.county will be  obtained  by  determining  at
            six-month intervals the new local programs which have been planned or
            enacted since the suggestions were made.

                    2nd year:   $30,823               3rd year:    $31,690
            Project  #28  -  Pediatric  Nephrology  Center  This  proposal       Requested
                           is for the establishment of a program for             First   Year
            end-stage kidney  disease  for  children  and  adolescents  at       $67,700
            Children's  Hospital  in  Columbus.  The  Center  will   provide
            diagnostic  and  treatment  services  to  kidney  patients,  including
            hemodialysis,  transplantation,  and  pre  and  post   transplantation
            supervision and care.  It also will serve as the source of information
            for the area  and  will  offer  training  programs  for  practicing  physicians
            and pediatricians.  All  activities  of  the  Center  will  be  integrated  with
            the Center for Adults in the  OSU  College  of  Medicine,  and  OSU  will  support
            a pediatric  nephrologist  to  be  recruited  for  this  Center.
                 2nd year:  $67,294                    3rd   year:   $70,384
            Project #27 - Cadaveric Transplant Program        It is planned      Requested
                           to establish  a  mddel  that  will  demonstrate       First   YeaK
            that an agressive program of organ procurement will                  $100,750
            increase the supply of organs, decrease the patient's costs,
            and improve the results of cadaveric transplantation.  This will
            be accomplished through three primary thrusts:  (1) public education,
            (2)  physician  education,including  patient  suitability   for   donation,
            procurement techniques, and legal responsibilities, and (3) training
            and utilizing allied health personnel to perform many of the tasks of
            organ  procurement  now  performed  by  the  transplant  surgeon.  The  project






             Ohio State Regional Medical Program  -13-                  RM  00022  5/71
             will cooperate with the National Organ Procurement Program and   obtain
           .continuing support by hospitals assuming part of the costs  through
             third party payments and local lay foundations.
                  2nd year:  $85,394                  3rd  year:  $90,194

             Project #30 - Program for Hypertension Detection  This              Requeste
                          three-year feasibility study is for the purpose        First Year
             of detecting hypertension and determining if effective means         $28,900
             can be devised to bring available methods of blood  pressure
             control to individuals in lower income groups.  A  public  education
             campaign will be launched, and a screening program  aimed  particularly
             at the black population will be carried out.  Individuals  in  whom
             hypertension is detected will be referred to either  their  private
             physicians or to one of several clinics to be set up in  the  Model cities
             area.-in cooperation with the Columbus Metropolitan Area  Community
             Action Organization., These clinics will be held during  evening  hours
             at existing clinic locations of Children's Hospital and will be staffed
             by project physicians and paramedical personnel trained throug  resources
             of OEO.

                 2nd year:  $29,956               3rd year:  $31,096
             Project #29 - Home Dialysis Program   To implement             Requested
                          dialysis training, two  dialysis coordinators     First  Year
             will be employed:  one in Dayton and the other in  Columbus.    $51,500
             Both will be trained in extra-corporeal technology and  will
             seek to establish patients on home dialysis at the  earliest   practical
             moment. In Addition, the coordinators will ensure  that  initial  pro  ems
             related to home dialysis are resolved.  It is hoped that after three
             years, the salaries of the coordinators could be assumed  by  third-
             party payments or local kidney association funds.
                 2nd year:  $53,100                       3rd year*  $56,010

             PROGRAM AREA: CO@ITY   RESOURCE SUPPORT
             Project l@35 - Centralized Hospital Pre-Admission Health           Requested
                          Evaluation  This project proposes the                 First Year
             performance of a total health evaluation as a part of             $19,966
             preadmission procedures at the five hospitals in the Greater
             Dayton area. It is expected that the  performance  of  preadmission
             tests for ambulatory patients in an out-of-hospital setting  will  shorten
             the hospital stay and result in reduction of per-patient costs and the
             freeing of hospital beds for use by other patients.  Specifically, the
             Region estimates that the community could save about $1,5 million  in  per
             patient costs annually and about $9 million in new hospital construction.
             Physicians will be able to obtain standardized, transferable medical profiles
             on their patients which will improve their management of  patients  and'
             through time saved, extend their services to more patients.  only one year's
             funding is requested.






            Ohio State Regional Medical Program          -14-                  RM  00022  5/71

                                                                                     Reques
                           Drug Information and Drug Therapy Aiiaylsis
            Project #32                                                                     te@
                           and Reporting Center  The services of the                 First Year
            drug information analysis center of the Ohio State University            $183,000
            (which has been operating  since  1962)  will  be  extended  and  regiona-
            lized. , It will provide health professionals with current and comprehensive
            information concerning drugs and drug therapy.  Although service' to physicians
            will be first  priority,  dissemination  programs  will  be  developed  to  expand
            the Center's use by pharmacists, dentists, nurses and other health, pra'c-
            titioners.  This is a one-year request only-

       VI. TERMINATING ACTIVITIES

            Two ongoing activities have no further     financial commitment   from
            and apparently are to be terminated.  No progress report on       these two
            projects is contained in this application:
            Project if4 - Careers in'the Health  Service  Program  and  Project  #6  -  Mobile
            Coronary Care Unit.  The Region will submit,terminal progress reports soon.











                                                                                                                                                   REVISED        3/9/71


                                                                                                                                RECT- Uli-
                                                                                                                                CYCLE
                                                                  BREA',KOUT OF REQU7-@-,          0 -1


                                                                                                                 'NE"!
                                                                                            ;PR-                                                                      TOTAL
                                      0-@
                                                                                                              IACTIVI'
                                                          ACTT'@ITIFS      ;RENELAL


                                                                                                                                                                       4 F ll_-@ 41
                                                                                            ';$450,870                                                37.1171

                                                                                                                                                                       174 391




                                      vallev
                              'P",    Val-,


                                      tetion Tra
                 AIIR      Tr.- ounty      Council                                                                                      1-0    049                       43,579
                                                                               40.049
                            for CE
                  @i!4    Cri@licil   "or   CE                                                                                             1.0,976
                                                                                               $10,97
                           (Portsr7ointh)                                                                                                      400
                                                                                                                                              9")O






                                                the                                                                                         32,410
                           Do
                           PO@FR Svqtem
                  #12              nfo,,."tion &
                           D'u", I

                            P(4i-.@ocial sel,vire
                                                                                                                                         lo.ooo
                                   Rel
                                         -T
                  #IL      cancer Monagpment

                    5@-       1ROSTital prt,-AInigsio@
                              l@h



                                                              $714,075       @122,068             $540,146         $456,603        ';$I,832,892      $186,456        $7,019,346















                                                                                               REGIO
                                                                                                CYCLE
                                                 BRZAYOUT OF REQuEsT      04            PERIOD


                                                                                     LN lzw
                                                                             'FU'
                          G'F                                          PR/UN      ACTIVITIE-
                                         iA

               CORE





                                                                                                       9,7




                @-I 5





                ':20



                                                                                                            0
























                                                                                                                                      27
                                                                                                                1 $192,850   $2,o64,7
                                                                        $561,5-       $507,257     $1,871,877
                                              $714,495      $SS,574
                                TOTAT,










                                                                                                                   B@EA'<OT,'T  OF  R7-QUEST                n5         PERTCD


                                                                   CO:@-JITL:TIG                               PaEvicusLy                                                                                                   -',@L        YEARS     ALL  YZ-ARS
                                      C-  c "I                    ACT7-VITIES           1  R           L      A?YR.                        @@CTIT,/-C-@-,S           DTPECT                                TOTKL                Dil@E                    AL
                                                                                                                                                                                                                                    CT          I  TO-i
                                                                $     586,561)
                                                                                                                                                                     586,569                                                       :$I,65@,364
                                  ICORE        SUPPLE.                                                          $485,000                                             485,nnO
                                                                                                                                                                                                                                    15,970
                                  44  PR
                                                                                                                                                                                                                                920.Onq
                                                                                                                                                                                                                                    41 , 7  75
                                  ff 2 R
                                                                                                                                                                                                                                    06,,q5f)
                                                                                                                                                                                                                                    .,)3,
                                       R                                                    $@9,688         i
                                                                                                                                                                                                                                IIQ.511         I
                                  1,41 L
                                                                                                                   64,000                                                                                                       I 8q,
                                                                                                                                                                       r,4    or)f)
                                                                                                                                                                                                                                    50,651
                                                                                                                                                                                                                                276.@"8
                                  Ilk? Q                                                                                                      7(),   ?RI-,                                                                      205,37,P
                                                                                                                                              56,oicl                  5.6, f) I  n                                             161,21n                   0,
                                                                                                                                                                       ?1.096                                                       8Q,952
                                                                                                                                                                       4r),121
                                                                                                                                              4 r
                                                                                                                                                                                                                                125,1@52


                                                                                                                                              lo.osL
                                                                                                                                                                       10.984                                                       ? 1   r-,4
                                                                                                                                              31,69C                                                                                2,511
                                                                                                                                                                       31,690
                                                                                                                                                                                                                                    9
                                  DEVET CP@-:E\TAL                                                                                                 187,187           187,187                                                    467,855
                                                                                                                                                                                                                                                          C-

                                                                                                                                                                                                                                                          t-4

                                                                                                                                                                                                                                                          tj










                                                                $586,569                  $39,688         1  -$578,743                 $523,966               1,728,866                                                     849,716;$5,433,635  i$5,983,789,
                                                                                                                                                                                    $170,850         $1
                                                     L





                               SUMMARY OF REVIEW AND CONCLUSION OF
                                    APRIL 1971 REVIEW COMIIITTEE

                               OHIO STATE REGIONAL MEDICAL PROGRAMS
                                       RM 00022      5/71

                           FOR  COiqSIDERATION  BY  MAY   3.971   ADVISORY   COUNCIL



            RECOIl[,IENDATION:  The  Conmiittee  recommended  that  the  PJAP  be  fun  c
                               at the level of commitment for one year only and
            that  two-stage  site  visit  be  made  to  this  Region   and   other   Ohio
            Wvs.  The Ad Hoc Panel on Renal Disease believed that two projects
            (Cadaveric Trans-plant Program and.Pediatric Neplirol               t@er) were
                                                                        -2,,)T C e
            worthy of support, but proposals for Program for EE --rtension  etection
            and  Home  Dialysis  Program   did   not   meet   technical   standards.

                                       (DIRECT COSTS ONLY)

                                   Contifluation --- Coi,.ii-nitinent.

                  Year                                                     Recommendation
                  03                         $714,075                          $714@075 1/
                  04                         $714,495                              -0-
                  05                         $586,569                              -0-
                  TOTAL                     $2,015,139                           $714,075


                                       Renewal Activities

                  Year                       @e   ues@                    Recommendation
                  03                        $122,068                               -0-
                  04                        $   88,574                             -0-
                  05                         $39  68?,
                  TOT-,%L                   $250,330

                                     @ti Tlenieiii-.al Funding
                  Ye-,qr                    @(luest                       Recommendation
                  03                         $996,749
                  04                        $1,068,808                             -0-
                  05                        $1,102,609                             .70-
                  TOTAL                     $3   168,166                           -- 0-

                                  Total Tri.c-n.1)
                                                 a@@-,quest
                  Year                                                    RecciTii,,iend-ation
                  03                        $1,832,892                          $7114,075
                  04                        $1,871,877                             -0-
                                            @i-  728,366                           -
                  TOTAL                     $5,433,635                           $714,075

                  $71-4,075 is the ar@,,ount of the original                    tl-ic n o-,,, -edijced
                  commitment di-le to P@' S fiscal cons-t-riin',.,@        $628,386.




            01110 S,ENI:E @ii,               -2-                            RM 00022 .5/71



             l@T Q@Ul,,: Since this Region has not received a site visit since
                       December 1968, and since the present trionnial'applicatioia appeared
            to be primarily a series of outlines vjliich conveyed to the reviewers
            little."feel-" for '-L.,c- Region, ti-ie Committee agreed that it  did
            not have sufficien!.- --'-nfbrmation adequately to judge the currenl-- status
            of the Ohio State         In addition  to  the  staff  concerns  listed  on
            pages one and two of the yell.ow summary, it was thobgli'L that the
            application  -presented  no,clear  evidence  of  accomplishments,  did   not
            alleviate  long-standing  concerns  regarding  the  merits  of  the   local
            continuing education councils, and certainly did not justify any
            supplemental support for this Region.  Further, the N!,DRMP's poor
            success  record  of  Council--approved  activities  caused  the   Committee
            to question the adequacy of the local review process.  The reviewers,
            too, were concerned  about  the  fragmentation  of  the  State  amonc,  the
            Northeast'Ohio, Northwest Ohio, And Ohio State Regional Medical
            Programs.

            In view of the above concerns  (and  also  the  sei@ious  probl-ems  in  the
            Northeast and Northwest Ohio M4Ps), ti-ie               was  that  the  Ohio
            State PID? should be supported for one                 yep,,!: at its commitment
            of $714,075*witti similar holding actions beiri- taken for the NI@,O and
            NWO Regions. Each of -L-be  tiaree  Regions  should  receive  a  site  visit
            to conc&iitrate on that@.1)@t:ograiii s problems, strengths, aiil i..,eal-,nesses.
            After these three inforinati6n-gatliering visit,.,  a  second-,,-,tage
            consultative visit should include the RAG chairmen, Coordinators,
            sponsoring  institution  representatives,  and  other   officials   of
            each program to discuss Amalgamation of the programs.  The one -
            year continuation of the three separate RifPs. then, is viewed bv
            the Review  Committee  only  as  an  interim  step  toward  the  unification
            of Ohio.


            Continuation Commitment:  Continual.-ion  funds  were.  requested  for  core
                                        and two ongoing activities (C@ ter- s@s s@t@
            Instruction And Ottawa Valley Continuing Education Council). The
            Review Committee acreed that the new commitment level of $628 386
            should be recommended for one additional year to support the        conduct
            of these  activities  and  other  approved  projects  into  which  the
            Region chooses to rebudoet, within 'this"le;vel of funding.

            Renewal Request: Ren,,aiq@il- support was requested for three Ongoing
                               activities:  Tri-.Couiity ContirLiinc, Education Council
            O@ro@i@r-Y Care Unit L q ning, and Stroke -Reliab@i.l.i.tati.,,)n       Al-tholi(,Ii
            no additional renewal funds were recommended for these projects,
            the Region is not prohibited from exercising its rebud-eliiig authority
            for their continuation.





            *Recently reduced to $628,386 due to RMt'S financial. st-itigc-nc-'Lc-@s.
     0




           OHIO STATE RMP                         -3-               RM 00022 5/71


           =Le eptallul                                                   the following:
                          _@ort_: Supplemental funding was  requested  for

               A. Developmental Component - In view of the  dearth of  information
                  About this Region, the problems cited above,  and  the  serious
                  concerns about the fragmentation of Ohio among t ree pro(,ra-ais,
                  developmental component funding was not recommended.

               B. Activation of Approved/Unfunded Projects  -  Supplemental  support
                  was requested forthe initiation of three projects and core expansion
                  for which previous Council-approval has been  given  but  for
                  which no funds have been  awarded:  Core  Expansion,  Greater
                  Portsmouth Area C2_tinu@ng Education Council, Pro raiii to
                  Improve Volunteer Services, and  Central  Ohio  Phonocardioscan
                  Screening. No additional funds were recommended for these activities,
                  although the Region may exercise its rebudgeting  authority  if  it
                  wishes, except for the $110,000 supplement  under  Core  Expansion
                  for the expansion of the program Health  Careers  in  Ohio.  In
                  view of the staff opinion that expansion of  this  program  exceeds
                  the bounds of permissible PJ.IPS support the Review Committee
                  recommended disapproval of supplemental monies for@health careers
                  activities.


               C. Initiation of Nine New Activities - Four  proposals  for  new
                  activities received technical review from the  Ad  Hoc  Panel
                  on Renal Disease. .Two of the Pro'ects (Cadaveric Tran      ant
                  Program ana.Pediatric Neph@olo      nter) were  considered  worthy
                  of support. However, the Ad Hoc Panel considered  that  the  other
                  two renal projects,      r@ for  Hypertension  Detection  and
                  Home Dialysis Program, did not meet technical standards and
                  should not be supported with RivP funds.  These four proposals
                  are discussed in more detail below.

                  The remaining new activities for which supplemental support
                  was requested were:  Development of PO@l@_y@teui in a Cq@mIL@
                  Hospital, Training P@@ail for  Medical  Social  Service  Personnel,
                  Cancer Management  Evaluation  Centralized  Hospital  Pre-Admission
                  Health Eva]-tia     and D)-uc, Info@
                                                     q_ttoL aii@@r@Tle
                  and  R60ort@   Center.   Consideri.ng @he lack  of  substantive
                  information about this Region, and the  problems  revolving  around
                  the fragmentation of the State into  three  separate  programs,
                  the Review CoiTmiittee could recommend no additional funds  for
                  the initiation of these new projects.  The Region is not prohibited,
                  however, from beginning  the  activities  through  rebudgeting,
                  if it chooses, except for the two projects specifically disapproved
                  by the Ad Hoc Kidney Panel.

                  Brief comments of the Panel on the four  renal  proposals  follow:




           OHIO STATE Ri4P                     -4-                 RM 00022  5/71


           Cadav6ric Transplant     The Ad Hoc Panel though the pro posal should
                                    be modified to reduce the budget by $28,000
           from $112,840 to $84,840.
           Pediatric Nep@rology@ n@te@ -  The Panel though that there was a
                                           distinct need for a pediatric nephrology
           program.  The approval by the Panel was only for "seed" money to
           hire core personnel to initiate a much-needed pro-rain, with  a  con-
           comitant reduction in the budget from $75,8   24 to $30,800.  Funds
           budgeted for the salary of a pediatric neptirologist should be utilized
           only when the applicant agency has recruited and hired such an individual
           to work on this specific proposal.


           Program for Hypertension Detection - The Panel considered this proposal
                                                  to be poorly described ai-id based
           on nonexistent data.. It lacks background,  method,  and  evaluation.
           There is no description of folloi,i-up and no control is evident  for
           this program.


           Home Dialysis ProRram - It was agreed thatthe proposal does not
                                    describe need and fails to define problems.
           There is no description of facilities or staff,  and  no  coordinator
           for the transplant program is identified.  The  plan  was  considered
           generally poorly written and thought out.  Further, there is no
           estimate of the number of patients.











                                                                        GRB/RMPS
                                                                       4/23/71







                                  RE(;@1014AI, MEDICAL PROGRAMS SERVICE
                     Sb.M,'4ARY  OF  AN  OPERATIONAL  SUPPLEMENTAL  GRANT   APPLICATION
                                     (A Privileged Communication)



               OHIO VALLEY REGIONAL MEDICAL PROGRAM
               1718 Alexandria Drive                                         RM 00048  5/71
               P.O. Box 4025
               Lexington, Kent c

               Program Coordinator:  William H.McBeath, M.D.


               'Ffiis application requests supplemental funds to support three new
               operational projects.  The Region's Triennial. application is due
               August  1971  and  will  be  reviewed  by  the  October  1971  Review  Committee
               and the November 1.971 Advisory Council.




                                      Requested (Direct Costs Only)


               Project # and Title          01  Year      02  Year      03  Year      Total

               #22 - Coordinating Pri-      $98,610       $96,410       $98,360       $293,380
                      mary Care for a
                      Rural Population

               #23 -  Regional Nursing      $89,123       $89,400       $92,000       $270,523
                      Inservice and
                      Continued     Education
                      (NICE)


               @,'24 - Intensive        Nurse
                       'training,,          $52,023       $53,689       $57,448       $1-63,IoO


                        TOTAL               $239,756      $239,499      $247,808      $727,063

               This Region was originally funded at $1,064,195         (d.c.) for its
               third operational year ending December 31, 1971.  However, due to
               RMP fiscal 1971-72 apportionment this total has been reduced by $88,331
               to $1,064,195. The Region received indirect costs of $278,993 for
               this year which represents an average indirect cost rate of 26%.

               Staff conducted its review of the Regionis application for the
               third year operational funding in December 1.970, and was satisfied
               that the Regi.on is niaki-ny, progress and noted (:hit ongoing activities
                        th@ Reglr)n's program "tlirtisti4"i4lil(,Ii were t,st.al)liqlied by
                        "iirin,,, 1969 ointl                             ,ttid iiioi-e i,t
                             (.,f ile.,iifi) )@iiiiii)(Pwel  for Ili(! (il' liiil)r@ovtd aiiil)ttltttt)rv





              Ohio Valley
              Regional Medical Program                       -2-                   RM 00048  5/71



                                             FUNDING     HISTORY



              Grant Year                        Period                        Funded (direct    costs)
                   01                        I/l/67-12/31/67                       $285,506
                   02                        1/l/68-12/31/68                       $320,092


                                            (operational Stage)

                   01                        I/l/69-12/31/69                           $799,195
                   02.                       i/l/70-12/31/70                         $1,214,460
                   03  (current year)        1/l/71-12/31/71                      $1,064,195 (of which
                                                                                     $25,000-is carryover)


              03  Listing  of   Funding,Status   of   Core   and Operational Projects in
               Ohio Valley  RMP
              Project                         Project                 Amount supported (d.c.)
              14umber                          Title                  Through 12/31/71
                 I           Core                                             $338,781
                 2 -         Community   Health    Staff    Development       $189,320
                 4           Library Extension                                  $88,332
                 5           University Continuing      Education             $120,262
                             Resources
                 6           Drug Information Service                           $12,500
                 7           Automated Multiphasic Screening                  $200,000
                 11          Rural Home Care                                    $90,000
                 13          Advanced Radiologic Technologist                   $25,000*
                                             -'TOTAll                        $1,064,195**



              *Carryover   funds.   This   project   will   be   funded through March 31, 1971.,
               at which time financial responsibility will be assumed by the National
               Center for fiealth Service & Research Development.

               'I'his amount has been    reduced by $88,331.  To $1,064,195, however, new
               budgets based on the reduced amount have not as yet been received by
               RMI:'S.

              SUMMARIES   OF   NEW    OPERATIONAL    PROPOSALS
              llroject #22     Coordinating Primary Care for a Rural Population               Requested
                               This three-year proposal is sponsored by the                   I,'irst Year
              fJnited Health   Services of Kentucky and 'I'ennessee, -in organiz-             $98,61.0
              ation  which  was  created  by   tlirc@e   comma.ini.ty clini.cs: (1) Cleit-





              Ohio     Vplley
              Regional    Medical     ProgrIam           -3-                            RM 00048  5/71


              Fork Community Development Projects Inc., Tennessee; Lawwell Fork
              Community   Clinic,   Inc.,   Kentucky;   and   White   Oak   Health   Center,    Inc.,
              Tennessee.   These   three   rural   clinics   which   operate   on   a   part-time   un-
              coordinated basis are to be joined into a single health care svstem
              to serve the 4,500 people along the Kentucky-Tennessee border.

              'I'lie  purpose  of  this  proposal  is  to  strengthen   and   expand   the-   primary
              lie,qltli  car(,  system  within  this  target  area  and   to   providp   a   capability
              I-or  co(:)rdinkit  ing  that  system  with  siii)portativ(,  @irid  specialized  service
                        the tiren.


              'I'o iiciiit-v(-     t.ii(, 1)rol)osni will 1)rovf(](@ for the Lr,,3iiiirig  of  fiill-
              I irTi(, nlirt;(, [)r,,ici it@ioners to @lttlf,f7 (.rich Clinic; t@tie  development  of   3
                                  1)roblem-(,)ritl@nt(@(I  medical  record  system;  the   establi.s@i-
              iric-tit of @j central staff Lo manage Lii(@ administ.ritioti affairs of the
              primary  care  ,iy-;tern;  and  the  use  of   family   health   workers   to   provide
              art (ilitrF.@ach and follow-up component.       A Llniversi.ty-related dental
              ser,jice  program  will.   also   be   established.   Each   clinic   will   be   staffed
              with a full-time nijrse practitioner, a health aide, a patient assistant
              and  three  or   four   family   health   workers.   Physicians   will   be   in   each
              clinic two days each week.

              Cooperative   Arrangements   will   be   developed   with   a   number   of    agencies
              and facilities outside the area.


              The   proposed   project   activities   are   related   to   the   Region's    "thrust"
              in that: they-

                        1.  Establish a mc-clititi,f.,;iii for coor(lintit:ing iii(@ primary
                            sy,,4t,(-tn of4 t'li(- ii reit iiit@ertiall,y iin(I wil@l-i (It(- ql)(@cit@lli.z(@(I
                            r(-soiirc(,.,; f'oijii(I e'lswl'iere.


                        2.  @@lil)port.. t.ii(,.traiiiin@! of- ntir.,i(@ pracL.ilioii(@rs to s(,rv(, ;is (.II(.
                            main providers of clinic services.

                        '3. Emp@)asj,ze   the   prevention,   education   ind   follow-tip    aspects
                            of comprehensive care.

              Specific objectives and an evaluation plan are presented.

              Second Year:   $96,410                                    Third    Year:     $98,360


              Project     #23  Regional Nursin  Inservice and Conti-nuing                        Requested
                                                  9
                               Education (NICE).   This proposal is sponsored                    First Year
              by the OVRMP in cooperation with a number of State hospital                        $89,123
              and Nursing Associations, State Nursing Flome Associations,                   Inservice
              F,(-IiicijLion (;roijp.,j and liaccalatir(@nt.e Ntir,,ing Programs.



            Ohio Valley                                            RM 00048  5/71
            Reaional Medical Program          -4-



            The proposal was developed in response to the need and interest
            demonstrated by these health agencies, institutions and organizations
            to provide continuing education opportunities for nurses in the Region
            It is designed to coordinate, collaborate and improve nursing inservi-ce
            and contintiiiig education throughout the region during a three-year
            demonstration period.
            The ultimate goal is to reach every health institution and agency in
            the Region and to offer expert assistance in evaluating and strengthening
            their individual educational programs.
            The program's activities will focus on three organizational levels
            which will be implemented by a full-time Regional Coordinator and
            three Area Coordinators:
            1.  Local or Individual Institutional Activity: The area Coordinators
                will provide the inservice and continuing education personnel
                in each institution with consultation and assistance in (a)
                establishing effective communication and understanding between
                the@inservice staff and the administrative and service staff; I(b)
                evaluating the program currently underway and recommending and
                assisting in the development of new elements; (c) identifying local
                sources that could be utilized to strengthen the instituti6n's
                program; and (d) applying technique to objectively evaluate nursing
                care so that areas of sub-optimal performance can be identified
                and educational programs focused on specifically identified needs
                may be designed.
            2.  Areawide or Multi-Institution Activities:  This approach is
                expected to substantially upgrade service.and continuing education
                among more specialized personnel in smaller institutions; and bring
                about more effective and efficient use of personnel and equipment

                resources.
            3.  Regionwide Programs:  This phase of the program activity will
                be organized on a regional basis and will involve the interface
                between the local inservice groups and the Region's baccalaureate
                school of nursing.  Short-term courses - three to five days --
                will be held and will be focused on locally ident ified needs
                that are region-wide in nature and will be designed for 30-50
                students.  Three such sessions were held during the past year and
                focused on such topics as stroke rehabilitation, development of
                nursing care plans and leadership and management of nursery
                service personnel.  It is expected that three of the six baccalaureate
                schools will offer such sessions each year.
            Second Year: $89,400                        Third Year:  $92,000





             Ohio Valley Regional Medical
                    Program                        -5-                   RM 00048  5/71



             Project #24 - intensive Coronary Care Unit Nurses Training     Requested
                           This project is sponsored by the College         First Year
             of Nursing and Health , University of Cincinnati,  and  seven   $52,023
             collaborating institutions: College of  Medicine,  Universitv  of
             Cincinnati,' American Heart Association (Southwestern  Ohio); @'eterars
             Administration Hospital Cincinnati; Cincinnati General Hospital;
             Good Samaritan Hospital, CincinnatiT Ohio Nurse Association and
             Greater Cincinnati Hospital Council. Proposed is  a  program  to
             provide short-term courses to prepare the registered  nurse  in
             the special knowledge and skills required for nursing in intensive
             f'Oronary care units so they can assume beginning responsibilities
             In a  coronaIry care unit.  The courses will- include theory
             presentation and laboratory practice at the College of Nursing and
             Health As well as supervised clinical practice in the intensive
             (-are units of three area hospitals. Each course will  be  four
             weeks long and will be repeatedfour times each year  for  three
             years.  IFourteen nurses will be accepted for each course, 56 per
             year, or a total of 168 nurses for the three-year period.

             Second Year:  $53,689                     Third Year:   $57,448


                                               GRB/RMPS
                                               3/18/71







                                                                (A Privileged Communication)

                               SUMMARY OF REVIEW AND CONCLUSION OF
                                                          'QMITTEE
                                    APRIL 1971  REVIEW  COi

                               OHIO VALLEY REGIONAL MEDICAL PROGRAM
                                         RM 06048 5/71


                    FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL



                RECOMMENDATION: This application  which  requests  support  for  three
                                 new operational projects be partially supported
                as follows:

                                                                      (DIRECT COSTS ONLY)
                 YEAR                                REQUEST            RECOMMENDATIONS

                Ist Year                            $239,756                $98,610
                2nd Year                             239,499                 96,410
                3kA Year                             247,808                  8,360
                  TOTAL (Dire@t Costs)              $727,063               $293,380
                CRITIQUEI  The Committee  noted  that  Ohio Valley RMP  will  submit
                           its Triennium  Application   for Consideration in the
                October/November 1971 Review Cycle.
                Since this  optional  application  Included only three projects,
                the Committee did not have an opportunity  to  study  their  potential
                impact on the entire program.. -However, it  wa  noted  that  Project
                #22 - Coordinati            Care for                      is an
                imaginative approach to the patient access  problem  and  is  directly
                related to the current OVRMP "Thrust" priority  -  "The  deve  opment
                and more effective utilization of health  manpower  for  the  delivery
                of improved ambulatory cAre." On  this  basis  the-project  is  recom-
                mended for additional. support.
                With regard to Project #23 -      lon@l Nursing In-Service  and  Con-
                tinuin@ Education, Committee  believed that while it relates directly
                to the Region's "Thrust" and  warrants approval, it does not have
                the unique qualities which would warrant additional funds.
                Committee recognized Project #24     Intensive Coronar,. Care  Unit
                Nurses Training tis the first CCU Training project  to  be  submitted
                by OVRMP and in fact might be a desirable activity for this Region.







               OHIO VALLEY RMP                    2                      RM 00048 5/71


               However, it was difficult to see how it relates to the "Thrust"
               which emphasizes ambulatory care, and it was believed that at-
               this point in time Regions should be trying to disengage,from such
               traditional continuing education type activities.  Committee con-
               cluded that while this project is not contrary to policy it is
               not the type of activity which should be encouraged and thus should
               be Approved without additional funds.



































                                                            GRBIRMPS/4/23/71





                              REGIONAL MEDICAL PROGRAMS SERVICE
                SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION
                                (A Privileged Communication)



                                                               RM  23-03  5/71
          Oklahnma Regional Medical Program
          University of Oklahoma                               April 1971 Review Committee
          Oklahoma City, Oklahoma

          Program Coordinator:  Dale Groom, M.D.

          This region is currently funded at $1,162,157 (direct costs)for its
          second operational year (which is a 13 month period) ending May 31,         1971.
          Core is supported at $390,000 (d.c.), 8 projects at $747,657 (d.c.)
          and Smoking & Health activities (Core) at $24,560 (d.c.).  The Region
          has submitted a Triennium Application that proposes:

                I- A   Developmental    Component
               II- The continuation of Core and four projects (5,6,8,10)
             III - The activation of 1 Council-approved but unfunded activity (#4R)
               IV- The renewal of two activities (#2R,#3R)
                V- The implementation of 6 new activities (#13-18)
               VI- The termination of two activities (#9 and Smoking & Health under Cote)

          The Region requests $2,020,565 (d.c.) for its third year of operation,
          $1,558,717 (d.c.) the fifth year and $1,422,759 (d.c.) for the
          sixth  year.  A  breakout  chart  identifying  the  components  for  each  of
          three years is  presented  on  pages  2-4  of  this  summary.
          One of the proposed new activities (#13) was previously reviewed an         d
          denied suoputt.  This point will be elaborated on later in the body of
          this summary-

          "hile a site  visit  is  not  planned  for  this  Reg
          A                                                   ion, a  Staff  review  of
          the application will be made an attachment to this summary.

                                       FUNDING HISTORY
                                       (Planning Stage)

          Grant Year                       Period                     Funded (d.c.)
             01                       9/l/66-8/31/67                  $142@250
             02                       9/l/67-8/31/68                  $249,017
             03                       9/l/68-8/31/69                  $323,993

                                       (Operational. Stage)
          (;rant Year            Period         founded  (d.c.)        Future Commitment (d.c.)
             01             5/1,/69-4/30/70     $1,074,143   I/             ----
             02             5/l/70-5/31/71      1,162,157                   ----
             03             6/l/71.-5/31/72     .   --                   $839,205

             The indirect   cost for the Region for the     current year is $'-@73,741 which
          represents an indirect cost rate of 23.5
          1/This award served to incorporate Core,      which'was being supported as
             a planning grant, into the operational     grant period.





                                                                                                             REGION         Oklahom;i
                                                                                                             CYCLE          RM 00023 5/71
                                                     BREP"KOUT OF REQUEST              03          PERIOD                 (Triennium Application)

       IDENT TFICATIO@N OF                  ICONTINUING
                                                                            !-PREVIOUSLY,      NEW
       COMPONENT                             ACTIVITIES     IRENE.7AL       !APPR/UNFUN.iACTIVTTIE             DIRECT       !INDIRECT         TOTAL
       Developmental                                                                             70,000              70,000                       @70,000
                                                                                                                 645    769    141 036-T
       CORE                                      645.769
                                                                                                                                                  786,805
      1#13 Regional Pediatric          Prog.1                                                      242,773          242,773    32,613             @.386
      1#14 Bartlesville Cont.        Ed.                                                         60,051      1        60.05
                                                                                                                                                  60,051
      1#15  Ada Cont. Ed. Center            i                                                    39,929             139,929                       39,929
       Y@16 Ada.   C.E.    Prog.    (stroke)l                                                                                                     77.0
                                                                                                 77$050              77,050                             50
       #17, Stomal Therapy and                                                                               7
            Catheter Care                                                                        63,748              63,748 1  23,261             87,009
       #I-t Nutrition    & Diabetes                                                              82,680           82    680    16,897             99

                                                                                                                    118,247    29,822    1        148,069
      1#3R  Emphysema    Program                                118,247
       #4R Enid Cont.     Ed. Center                                             42,104                              42,104                       42,104
      1#2R Coronary Care for Oklahooa                           247,459                                             247,459    61,367             308,8
      1#5 Tulsa Cancer Control
           Program                                 58,200                                                            58-200                       58,200
      i#6  Library   & Info. Services              52,674                                                            52,674    15,933             68.
      i#8  Mamography                          114    460                                                           ii4.460    43,330             157,790

                                                                                                                    105,421                       128
      !#IO    Regional    Urology    Program@     105,42,                                                                      23,355




                                                               365,706         4             636,231         !2,0203-       1   387,6.14          8
                             TOTAT,             7 6, 5                                                                  565                    2,40


                                                            ;I                   t,,: .
                                            I                               I                                                            I
                                                            I



                                                                                                               REC,ION          ,@I)klaltoma
                                                                                                               CYCLE             RM          5 71
                                                     BREAKOUT OF REQUEST                              PERIOD


    IDENTIFICATION OF                       CONTINUI\C,                      i!PREVIOUSLY-'      NEW
    COVPONENT                              IACTIVITIES       ;RENEWAL                 jAPPR/UNFUN.;ACTIVITIES     DIRECT        !INDIRECT           TOTAL
     Developmental                                                                                  70,000       1 701000                            701.000

                                                                                                                                                           277
     CORE                                     664,277                                                             66@,277                          6643

     #13                                                                                             379.9-@4     379,944                              379,944

     #14                                                                                            40.711         40.711           ---              40.711

     #15                                                                                            39,028         39,028                            39,028

     #16                                                                                            70,853         703853                            70,853

                                                                                                                                                     88,476
                                                                                                    88,476         88,476.
     #17

                                                                                                                                                     86,799
                                                                                                    86,799       i 86,799

     lk3R                                                         118,629                                         118,6'1'-9                           118,629

     lk4R


     #2R

    '#5

    :#6


     #8                                                                                                                              ---           ---

    l@#io





                             TOTAL            664,277             118,629                             775,811    19558,717                           1,558,717






                                                                                  BREAKOU'L-        OF         REQUEST   05         PEr\ioD


                                     CO'@TTI,@UT                                         USLY'                   NEi-7                                                                    AL
                                                  -,N G                        P-\,_, VI o
                                                                                                                                                                                           L     'iEARS       ALL YEARS
       LO-F-C D-     O@@'E Y- T      ACTIVITIES             R   N F l,A L     APPR. /UNFU,14.             ACTIVITIES!             D'l r,   CT     INDIRECT                 TOTAL      DIRECT                  TOTAL

       iDevelo mental
                  p                                                                                       70,000                  70,000                            70.000                 210,000            210,000

       CORE
                                         690,539                                                                                      690,539                           1690,539              2.000,585          i2,141,621
       #13                                                                                                         065                343,065
                                                                                                        343,                                                            @343,065           965,782            998.395
       #14                                                                                                43,341                  4j,J41                            43,341                 144,103            1'44.103

                                                                                                          39.865                  39,865       1    ---
       #15                                                                                                                                                          39-,865                118,822            118,822
       #16                                                                                                73,746                  73,746                            73,746                            9
                                                                                                                                                                                           221.64             221.649
       #17                                                                                                91.109                  91,109                            91,109                 243,333            243,333
       Yil8
                                                                                                          71,094                  711094                            71,094                 240,573            257,470
       #3R
                                                                                                                                                                                           236,876            266,698
       YA4  R                                                                                                                                                                              42,104             42,104
       #2R
                                                                                                                                                                                           247,459
                                                                                                                                                                                                              308,826
       #5                                                                                                                                                                                  58,200             58,200
       #6
                                                                                                                                                                                           52,674             68,607

                                                                                                                                                                                           114,460            157,790
       #8


       #10
                                                                                                                                                                                           105,421            128,776






                                        690,539
                                                                                                       732,22,r,.--@,         @,422 759                         @1,422,759         15           002,041                  94
                             *:To  be  negotiated




          Oklahoma Regional                  -5-                        RM 23-03  5t7l
        r Medical Program

          GEOGRAPHY - DEMOGRAPHY - CHARACTERISTICS:


          From the beginning this Region has been defined as the State of Oklahoma.

              1)  Popul ation-2.52 million (as of July 1,1968)
                    a.  63% Urban
                    b.  90% White, 7% Negro, 3% Other
                    C.  Median Age-30 years (U.S. average 29.4) 1960
              2) Land Area - 68,887 square miles
              3) Health Statistics
                  Death Rates by Selected Causes/100,000 - 1967, Unpublished
                    a.  Heart Disease - 368.8 (slightly higher)
                    b.  Malignant Neoplasms - 157.6 (slightly higher)
                    c.  Vascular lesions - 127.4 (high)
                    d.  General Arteriosclerosis - 19.9 (higher)
                    e.  Diabetes - 21.4 (very high)
              4) Facilities:
                    a.  University of Oklahoma School of Medicine - enrollment 396
                    b.  Schools of Nursing - 11 (3 college or university affiliated)
                    c.  Schools of Medical Technology 13
                    d.  Cytotechnology, University of Oklahoma (1)
                    e.  There are 138 hos'itals with 19,202 beds
                                          p
              5) Personnel Statistics:
                    a.  As of 1967, there were 2,904 physicians (2,483 M.Ds and
                        421 D.O.s) for a rate of 119/100,000.
                    b.  As of 1966, there were 6,582 total nurses of which 4,435
                        are employed.



                              Map of Oklahoma's Major Cities & Population




                                                        BARTLESVILLE 0
                                                        30,000
                                           ENID
                                            0,000                      dl TULSA
                                                                          280,000
                                                                MUSKOGEE
                                                                 38,000

                                                          0 OKLAHOMA CITY
                                                                380,000
                                                                         Mc ALESTER
                                                                         17,419
                                       [A
                                                                      ADA
                                                                      14,347




           Oklahoma Regional                                                   RM 23-03    5/71
           Medical Program                     -6-


           HISTORY & DEVELOPMENT
           ThIe Region received an initial planning grant of $142,250 (d.c.) for the
           year 8/l/66-8/31/67.
                                                                        (d.c.) was
           A second year planning grant in the amount of $249,017
           awarded for the period 9/l/67-8/31/68.
           i\ third year planning award of $323,993 (d.c.) for tile    period 9/l./68-8/31/@)9.
           In September 1968, LliL- Region submitted an operational.      application
           consisting of t(.!n projects.
           Er, 4ovf.!rnb(!r 1968 a pr(---operational site visit was conducted to tile
           @.egion.     team consisted of Henry Lemon, M.D. , I,,lliott Rapaport, M.D. ,
           Ralph Ingersoll,  Ph.D.,  and  RNPS  Staff  Anthony  Komaroff,  M.D.,  and
           Patricia  4cDonald.  The  visitors  were  favorably  impressed  with   Dr. Dale
           Groom, M.D., who was  in  the  process  of  replacing  Kelly  West,  M.D., as
           Coordinator, noting he has a good background for the position.  However,
           it was evident that Dr. West would still be actively involved i       n ORNP.
           The 'visitors were convinced  ORNP  was  a  true  Region  centering  around
           the Oklahoma Medical Center as the focus of higher medical education
           in the State and there was evidence of ties between the Oklahoma Medical
           Center and its affiliates and the physicians of the surrounding cities
           and towns, including Tulsa. It was noted that in some cases the ORMP
           activities extend into other adjacent regions and vice-versa, however,
           tile arrangetiient appeared to be working well.    The  visitors   observed
           several. shortcomings in  t[i'c fleploti,     were:   the   org@InLzation,
           (:ornpo-;ILLon ;ind rote of tile RA(;; tile absence of a well.-IiitegraL(id pl.an
           for Ltic (I(-.vt-lopnient of tile Oklahoma program; the fii.,].tire to think about
                  priorities; tile (ionilnallon of the program by the University;
           and tike nee(i for nurses, hospital administrators, persons from tile. periphery,
           c-tc. tr; tak,(@ @.in innovative rol.e. On the other hand the visitors noted
                wc--rc-, capable persons from tile periphery who had an obvious Interest
           @n (jR.4P, and in particular the strong Tulsa group.      There appeared to
                                                                      ce of tile    dical
           le capable leadership of the program and the excellen                   me
           school which represented special categorical strength appeared to indicate
           the wisdom of providing operational funding.
           As a result-of the pre-operational site visit the Region became operational
           on 5/l/69 with an award of $1,074,145(d.c.) for support of Core and nine
           operational projects for the period 5/l/69-4/30/70.  This award served
           to incorporate Core, which was currently being supported as a planning
           grant, into the operational grant period.
           In Apri.1 1970 Staff reviewed the Region's 02 continuation application.
           @taff, noting that Dr. Croom Is the only full-time 1)liyslciin oil (ore
                       r.,)nct!rni@(I ;jt)oliL Llit, d(-grcc! of iiviilliil)lv
           It            ori(--d why
                        I          the full-time M.D. position of                 (,oLirtiLnzitkit,
           was Still va(.,,arit. Con(--ern was also expressed over four of the Core ;t@iff
                             -illed by retired Air Force
           positions being I                                Officers who had no
           prior health related experience.  It was felt the proposed full-time
           coordinator for  Tulsa  area  would  lend  strength  to  the  program  but
           that the functions of the positon needed to be clarified.  The appropriateness




          Oklahoma Regional
          14edical Program                            -7-                               RM 23-03  5/71




          of  the  initiation  of   a   number   of   feasibility   studies   was   questioned   and
          it appeared as if it was premature utilization of developmental component
          approach.   The responsibilities of the RAG in relation to the feasibility
          studies were questioned.   The functions of Core staff in the initiation,
          conduct   and   evaluation   unapparent,   and   Staff   seemed   more   devoted   to
          Initiating   a   series   of   pilot   activities   in   prevention.    Staff    concluded
          It was uneasy about the developing program in Oklahoma and the influence
          and dl@rection the Core Staff was executing on ongoing activities.
          Staff recommended that the continuation appl.@Lcation be approved as requested
          bzit  also  that   staff   visit   the   region   to   gather   additional   information
          regarding  the  cited  concerns...   The   Region   received   an   02   year   award
          of   $1,162,157   (d.c.)   for   Core   and   eight   projects,   with   restrictions
          pending additional information.

          On July 15,-1970, the Region responded to the major concerns cited
          in the April Staff Review and for the most part answered them
          satisfactorily;   qualifications   for    the    Tulsa    Coordinator    were    outlined.
          The   decision-making   process   for    feasibility    studies    were    described,
          And  additional   insight   was   provided   on   Core   Staff's   functions   as   they
          relate   to   ongoing   projects.   However,    little    information    was    provided
          as  to  how  the  activities  of  the   Tulsa   Core   Staff   would   be   monitored.

          On  July  22,  1970  a  visit  was  made  to  the  Region  by   five   members   of   RMPS
          taff.:   Frank   Mark,   M.D.,   Julia   Kula,   David   Peale,   M.D.,   James   Gross,
          .D., and Frank Zizlavsky.   The visitors found overall pl.annlng methodologies
   Ow,mer(!   not   sufficiently   developed   and   only   recently   had   a   director    of
          planning I)L@i@n           'Pi,ic!  Coordinator  felt  many  of   the   deficiencies   in
          anjilicationF; rerijlte(I from  inck  of  ptil(,Ian(,e  froin  RMPS  on  how  to  (levelo'
                                                                                                  T,
          apnlir-ations.    Professional           Staff ryionitoritip, of projects was t(ient@ifitd
          as lpirig Ina,leqtlate   a,-; lead I)een past proj@,reAs reports.      The              believe
          a  larg(-  per(-entage  of  the  monetary   resources   were   going   Into   the
          7,.@c-dical  centers  where  tl)ere  was  a  general  reluctance   of   some   project
          directors  to   move   project   activities   from   the   medical   center   base   into
          "have not" areas.   The planning, ediomological, health services an
          other  resources  of  the  School  of   Public   Health,   which   is   within   a   few
          blocks  of  the  Oklahoma  RMP   and   would   be   most   useful,   essentially   are
          not   being   used.   General   recommendations   resulting   from   the    visit    were:

           1.   That   a   professional   core   staff   person    be    delegated    responsibility
                for continuous surveillance and monitoring of each project.

           2.   That   an   overall   plan   for   the   development   of   regional   planning
                methodology,  based   on   a   systematic   approach,   be   (I(@vel.ope(l,
                including   identification   of   the   person   who   wil.1   have   major
                responsibility.

                                   Ar(.a ,4tjbregional  Coordinator  zitt(,n(.1  s(,iiiinirs  or
                                                                                       -tio
                             in c-orrfrntinity         planning and (,oinititttiity I(    11
                ;ieader@hili  type   programs   and   develop   and   submit   @i   subregional
                plan to the coordinator.





        Oklahoma Regional Medical
            Program                         -8-                      RM 23-03  5/71
          4.  riiat categorical committees should serve as strong technical.
              reviewers for the RAG.
          5.  That cooperative arrangements be undertaken between the School
              of Public Health and ORMP.
          6.  That the incoming ORMP supplement for additional Core staff
              be given consideration in view of existing needs.
          7.  That the-Region be informed that responsibility for demonstrat;.ng program
              an(] values of individual proposals rests i,;ith OPMP staff.
          8.  That a chairman of the Cancer Committee be appointed in the
              near future.
          9.  Restrictions placed on the 02 year award be removed.
                                                     commendations which related
        fii f)ecember 1970 Staff responded to those re
        to the Region.  While some questions wore answered directly, others
             4) were deferred to the Triennium Application which  would  shortly
        he submitted to RMPS.
        A report on program progresn during the first two years of  the  program
        is on nages  16-21.


        PROGRAM PROPOSED IN PRESENT APPLICATION
        .Goals and Obiectives:  Th ese goals and objectives not radically different
                                from those originally projected (see pagel6), their
        order varies somewhat there is some inkling that the accessibility problems
        are important.

        Overall Coal: To assure that the highest possible standard of medical
                      care is equally available to all citizens of the Region
        for control of heart disease, cancer, stroke, renal and other major
        and related diseases deemed to be within the scope of the Regional @ledic,'Il
        Program Act, as amended.
        Sub-Goals   To provide the Region with leadership and guidance in developing
                    and deploying its health resources to control heart disease,
        cancer, stroke, renal and other major and related diseases.
        To act, by all appropriate means, as a major catalyst and enabler -in
        the formation and perpetuation of more effective and efficient
        cooperative arrangements for the. delivery of better health care to  the
        citizens of the Region.
         0 explore the future directions of the health care system and  to  make
        positive contributions through demonstration and implementation  to  the
        evolutionary development of the system.






          Oklahoma Regional
          Medical Program                      -9-                    RM 23-01      5171



           Obiectives.

           Develop ways and means of achieving understanding and cooperation among
           hospitals, educational institutions, voluntary and public health agencies,
           comprehensive health planning and other groups to improve medical care
           in the Region.

           Promote the life-long continuing education of physicians and other health
           related professionals within the Region.

           Encourage the development of adequate health manpower resources to meet
           needs of the Region.

           Improve the quality and quantity of, the delivery of health care at the
           community level throughout the Region.,
           Where ,ippropriate, every action and activity of the Okl-alioma Regional
           Medical Ilrograiii wl.11 iiiel.tide public education and wil-l- be directed toward
           promoting a greater understanding by Lli(@ citizens of the ]@egi.on and of
           the need for   and means of obtaining, high quality health maintenance
           and care.



           Regional Advisory Group-:
           The RAG consists of 53 members.  While there is considerable dual
           representation by many members, representation can be categorized
           basically as follows:
             1. Practicing Physicians    12             9. Consumer - 4
             2. Medical Center Representation    3            2-Indian
             3. Hospital Administrators - 3                   I-Black
             4. HeAlth Related Professions - 8                1-White
             5. Voluntary Health Agencies'- 3           10. State Government - 2
             6. Medical Professional Society - 9              1-Planning Agency
             7. Educational Institution - 2             11  Health Insurance
             8. Labor   2                               12. Industry - 2
                                                        13. V.A. Hospital   2


           Committees:

           In addition to the Steering Committee there are 12 working committees
           which are expected to provide the ORMP RAG with essential guidance anti
           professional expertise in the following specific areas of responsibility.
             1. Heart Disease                             8. Hospital Services
             2. Cancer                                    9. Out-of-Hospital Medical Services
             3. Renal Disease                           10. Continuing Education
             4. Pulmonary Disease                       11. multiphasic Screening and
             5. Stroke                                      Automated Data
             6. Related Diseases                        12. Nutrition
             7. Manpower and Education




       Oklahoma Regional                       -10-                  RM 23-03        5,/71
       Meclical Program



         Review and Evaluation:
         A flow cliart.of review and evaluation is presented  on  page  22.


         Subr(,gionalization:
                                                       roups has been urged  by  core
         Formation of Sub-Regional or  Area  Planning  G
         staff from the earliest planning  stages  of  0    however,.being able
         to offer little incentive or assurance of support  to  local  action  groups
         for planning and development activities,only three  such  groups  have  been
         organized; Ada, Tulsa, and Enid.  Two other areas have indicated an interest
         in forming such groups: Lawton and McAlester and  core  staff  is  currently
         .assisting in the effort.
                     -L -Om one-                                   Requested
         Develo mental Component:
                                                                   First Year
         The Region sees the developmental component   as           $70,000
         serving basically two major functions:(l) promoting
         collaborative and cooperative endeavors among components of the health
         care system through  financin  of  pilot/feasibility  studies  and
                                      9
         (2) establishing a more adequate data and information base for action
         planning through up-dating that which is already available and obtaining
         new and different types of data and information.
           specific protocol is outlined identifying  the  roles  of  core,  steering
         committee and RAG in the promotion,  development,  and  review  of  requests
         for developmental support.

          second Year: $70,000
                                                          Third Year:  $70,ooo



          Core: Core is currently  funded  at  $360,000,
                                                        for a 13      Requested
               .month period, which supports an equivalent of         Third Year
          26 full-time positions: 16 professional and 10
          secretarial.  Request is being made to increase Core        $645,769
          staff to an equivalent of 43 full-time Positions; 27
          Professional and 16 secretarial.  (See page.14 for outline
          of current and proposed positions).

          i-'oljrtfi Year: $664,277               ]-'iftil Year: $690,539



              Oklahoma Regional                                         RM 23-03  5/71
              Medical Program



              '@roj_@ct l@CqLl(--,13Li by Disease categories:
              Included in these summaries is the priority given  each  by  the  RAG.


              Heart & Stroke
                                                                                  Requested
              Project #2R-Coronary Care Program for Oklahoma - Oklahoma           Third Year
                          Medical Center                                          $247,459

              (Priority 1) This project which is in its 02 and final year of operation
                          was initially funded at approximately  l@  the  original
                          request for 2 years, as a feasibility study.  A summary
                          of progress is on page 16,

              9@ec@Lves_:  Request is being made for which one year o  renewe
                          support for this project is  designed  to  create  acute
              coronary care units in hospitals financially unable to develop complete
              coronary care units.  During this year effort will be made to expand
              coronary monitoring into the northwest portion of the state and
              into Public Health  Service  Indian  Hospitals.  Sixteen  new  remote
              coronary beds are proposed bringing the total  by  completion  of  the
              project to 56 to 59 beds.  Plans include continuing education programs
              for physicians, nurses and paramedical personnel.  The training of
              Job Core students as Coronary Care Technicians will continue.  Equipment
              categor  represents $77,318 of the total budget request
                     y

              Project #16-Ada Area Continuing Care Program (Stroke)-            Requested
                          Valley View Hospital                                  First Year
                                                                                  $77,050

                 ec@l e@s: To develop a team which will. provide rehabilitation
                          services to hospitals and nursing homes throughout
              the area. Ilrovldc@- i series of stroke workshops and seminars  for
              p , , ,     nurses, and other a] lied health personnel in  the  area.
               .iysicians .
              A survey will be initiated to determine  more  precisely  the  extent
              of the  stroke problem in the area.
              -Second Year:  $70,873                     Third Year:  $73,746


              Cancer
                                                                                  Requested
              Project #5-Tulsa Area Cancer Control Program                        Third Year
                                                                                  $58,200
              (Priority 12)This project Is currently in Its second yc,.,ir of
                          operation, third year committed support Is ])(:,Ing
                          requested. A c3tirriiii,.iry of I)rogr(-,;s is oil I)ag(, 17.



              Oklahoma Regional              -12-                      RM'23-03   5/71
              Medical Program



              Objectives: The most  important  intent  is  the  continuation  of  a
                            Cancer Control Clinic in the Tulsa Model Cities target
              Area.  This clinic screens adults (most negro) over 40 for the 5
              most common malignancies and includes instruction of patients being
              examined. The project  will  also  provide  for  the  continuance  of
              the computerized registry and the surgical residency training
              program which provides a mechanism for direct contact with young
              surgeons planning will be continued with the liillcrest Medical
              Center in  reference  to  the  rehabilitation  center  currently  under
              construction.
              -Prriject #8-A                                              s of Breast  Requested
                                                                           Oklahoma     Third Year
                          Medical Center                                                $114,460
                            This project is currently in its second year of
                           operation, third year committed support is being requested.
                           A summary of progress is on page t,7.

                       s: Development of  multiple  clinics  in  remaining  quadrants
                          of the state.  Continue the training program for resident
              radiologists at the Medical Center Breast Clinic Continue the,affiliatioin
                       for both  registered  and  student  radiologic  technologists.
              programs
              I.nitiate an all'out publicity and community awareness program.
              Project #10- Reg    al   Urolo.gy Project with initial Em-ohasi.s on     Requested
                           Cancer of the Prostate -   Oklahoma Medical Center          Third Year
                                                                                        $105,421
             (Priority 4) This  project is currently   in its second year of operation,
                           third year committed support is being requested. A
                           summary. of p@ogress is on page 18.

                         This project is entering its third    phase  which  is  to
                         initiate  continuing  education  programs  based  on  data
             collected in an indepth study of six sample groups of the total
             project  representing  different  sett'ings of urologic care.  The
             addition of further study will provide correlated information which
             will be more reliable and specific for continuing education purposes.
             Public attention to preventive measures will be strengthened by
             appropriate use of collected data through the areawide Comprehensive
             Health Planning Program.
             Project #17 - Stomal Therapy and Catheter Care       Okl.alioniii         Requested
                            Medical   Center                                           first Year
                                                                                       @63,


                       7,

                                  I)li.sli a iijodL--l
                          Clinic at the Oklahoma Medical (,c!tiLer which will ,;t@rve
              as a training base  for Nurse-ther.apists from throughout the Region,




            Oklahoma Regional
            Medical Program                                          RM 23-03  5/71


            who will return to tf@eir areas, identify local needs and resources,
            and with assistance of the project  director  develop  local  clinics
            for education, training and service overall objective is to provide
            optimal care patients with a stoma or indwelling catheter by
            teaching self-care and continuity of care through coordinated
            community resources.

            Second Year:  $88,476                        Third  Year:   $91,109


            Related Diseases                                                    Requested
                                                                                First Year
            Project.#3R    A Regional Emphysema Program    Oklahoma Medical     $118,247
                           Center
                           This is a renewal request of  a project which
                           was approved and funded for 2 years an  is
                           currently in its final year of operation. A
                           summary of progreRs is on page 11).

               ctiv@:      Maximum effort will be made by the  four  teaching
                           and center which were established during tile
            first year to provide more training and intensive education programs
            for the health professionals.  Programs will be conducted for
            physicians, nurses, inhalation therapists,  and  other  professionals
            in the units  and  in  pulmonary  function  laboratories.  Practicing
            physicians and nurses will work and train in  the  established  units
            for a week or more at a time.
            Second Year: $118,629
            Project #13- Regional Pediatric Program with Initial Emphasis       Requested
                         on Indian Children - Oklahoma Medical Center           First Year
                                                                                $242,773
            (Priority #10) This project was previously  reviewed  by  Committee
                           and Council and support  was  not  recommended.  Its
                           relationship to the ongoing  program  was  not  clear,
                           it was training physicians with only two-year com tments
                           and training' would  involve  sophisticate  equ  pment
                           which would not be available to the  physician  in
                           actual practice.

            Objectives:    Emphasis will be on  Indian  population.  Visits  will
                           be made by specialists in pediatrics  nursing  and
            nutrition to Indian Health Service Units  for  consultation  with
            and teaching of IHS medical officers, nursing  and  dietetics  staffs
            of the Service Unit Hospitals and health centers, and the Community
            -Health Representatives who serve Indians in  their  communities  and
            homes.  The training program for IHS medical officers will be coordinated
            with the activities of the local pediatricians who provide consultation
            to Indian hospitals under  contract  with  !HS.  D61ivery  of  health
            care and nutritional education to the  Indian  population  will  be
            provided through expansion of  the  Community  Health  Representative
            Program of IIIS and development of a training  program  for  CHR'S.
            Sixteen new CHR's will be supported  by  the  project.  Education  in
            nutrition will be directed to all members of the health team, particularly
            CHRs Neonatal Care Centers and Pediatric  Oncology  Centers  will  be




             Oklahoma Regional
             Medical Program                  -14-                     RM 23-03  5/71

             established in outlying community hospitals.  Urologic and cardiac
             screening will be expanded.
             Second Year:  $379,944                      Third year:  $343,065

                                                                                  Recuested
             Project #18   Nutrition and Diabetes    Oklahoma Medical Center      First Y'ear
                                                                                  $82,680
                           This project is an expansion of a project by the
                           same title which has been funded during the first
                           two   operational.years.  A summary Qf Project #9 is
                           on T)age 1.9.
             )Lb  ct v@P-   rraining.and,recruitnient of nonprofessional dietary
                           manpower for  smaller  institutions.  Advanced  training
             for food service supervisors.  Provide dietetic consultation to
             smaller hospitals to include development and distribution of resource
             and continuing.education material.  Demonstrate out-patient diet
             counseling services.
             Second Year:  $86,799                      Third Year:  $71,094



             Education    General
                                                                                  Requested,
             Project #4R -.Continuing Education Pr  ram for Enid Area     St.     First Ye
                            Mary's  Hospital                                       $42,104
             (Prio--it7 1)  Renewal nf this nroject hqs been previously ipprove(i by
                            committee and Council but has not been funded.  A
                            summary of project to date is on page 20.
                     es:  Develop   way.s and means of achieving cooperation in
                           continuing education endeavors among hospitals,
             educational institutions, and other groups.   Promote life-long
             continuing education of physicians and other health-related professionals
                                                     tion in personal contact,
             through: 1) improved regional communica
             T.V., radio, print, etc., 2) continuing education programs, 3) extension
             of educational resources; Oklahoma Medical Center teaching hospitals
             and institutions, 4) development of self-education programs.
             Project4@6- Libra    and Information Services - Oklahoma Medical     Requested
                          Center
                                                                                  $52,674
             (Priority 11) 'fhis ongoi.ng project is requesting 03 yc,,ii-
                           c;cjmmitted fitjl)f)ort. A stililryint@, ris )tl
                          I!@iprov(-- inforiiiatloji -ic@rvlc(@@@ tt) 1)liysi.(-i,,iii,,; ,iiiki ot-11L,I-
                                           riiils In tlic-    I)y I)t@@Liig Liiimt@tliiit(-@Iv
                          tic-,tllii I)rofc@sito
             responsive to requests for medical information.  Aid physicians
             and other health professionals in the rural  areas.  Increase the
             scope of information services and the speed of their delivery.  Provide
             continuing education of untrained hospital librarians and consult




             Oklahoma Regional
             Medical Program                 -i5-                        RM 23-03  5/71



             with hospital administrators in an effort to upgrade hospital
             .Libraries.

             Project #14 -Continuing Education Center for Bartlesville Area-       Requested
                          Jane Phillips Episcopal Memorial Medical Center.         First Year
            (Priority 6)                                                           $60,051

             Objectives:  Establish a mechanism for providing continuing education
                           for health professionals in a  basically  rural  area  of
             Northeast Oklahoma.  Modalities employed would consist of teleconferences,
             seminars, workshops,video-tape programs  and  a  regional  TV  network.
             Promote communication and cooperation among various individuals,
             institutions and agencies which will lead  to  joint  efforts  to  meet
             mutual problems of continuing education.  Increase communication
             between the Oklahoma Medical Center and local health-related professional
             and institutions.  Improve public and patient education.

             Second Year:  $40,711                       Third Year;  $43,341



             Project #15 - Ada Area Continuing Education Center - Valley            Requested
                            View Hospital                                           First Year
            (Priority #5)                                                           $39,929

             objectives: Establish a mechanism   for providing continuing
                         education for health professionals in a basically
             rural area of Southcentral and Southeastern Oklahoma
             Modalities would include: a telephone network with visual aid
             support, indepth workshops and  seminars,  A  health  science  library,
             a tie-in to closed circuit television system for higher education
             in Ardmore.  Promote communication and cooperation among
             various individual. institutions and agencies which will lead
             to joint efforts to meet mutual problems of continuing education.
             Increase communication between the Oklahoma Medical Center and local
             health-related  professionals  and  institutions.  Improve  public  and
             patient education.
             Second Year:  $39,028                              Third Year:  $39,865





          ok'Ahoma Regional
          @it,(Iical Propi-am                                        RM 21-01    5/71


          ORIGINAT@ OBJECTIVES OF PROCRAM AT  TIME OF OPERATIONAL APPLICATION


               a.. Provide leadership and guidance in developing and deplo7ing
                   the Regioil's health resources to control heart disease,
                   cancer, stroke and realted diseases.

               b.  To ,Iissist tile grantee insititution, the University of Oklahoma
                   Medical Center, in effectively discharging its responsibilities to:
                      .(I) Develop and promote cooperation between the many components
                          of the health care delivery system to improve medical
                          care throughout the Region.

                      (2) Promote the life-long continuing education of physicians
                          and health-related professions.

                      (3) Increase the standards, efficiency and effectiveness
                          of medical care at the community level and make more
                          widely available the potentialities of medical science.

                      (4) Utilize all the resources at its command in collaboration
                          with the physicians, community hospitals and voluntary
                          health a encies of tile State.
                                  9

                      (5) Ilrov-fde tile Intellectual CTIViroiimeiit and incentives for
                          attaini.nc!nt of the above objectives.

                 'I'o ,j i-- tas a rna.lor catalyst l.n the formation and perpetuation
                 of   a more effective and efficient cooperative system for tile
                 delivery of. better health care to the citizens of Oklahoma.



         Projects


         Projects supported during the first two years of operation are summarized
         by category as follows:



         Heart
         Project #2 - Coronary   Care Program for Oklahoma    Oklahoma Medical
                       Center


               Funded fleriod: 5/69-5/71
                              Ol-$1901000              02-$I.99,600

                           Creat(-- acute coronary care beds,in lit)--,I)ita.Is fitiiticiatl,%
                           Unable to develop complete coronary care Litiits.   The
                             for the development of 14  "central  monitoring  units"
               program calls
               (CMUS) in larger urban hospitals. The  CNIUS  will  monitor  electro-
               cardiographic tracings relayed continuously be telephone lines from








          Oklahoma Reuional
                     t,
          Metilcal PT-ogi-am                  -17-                 RM 71-01         S/71


              patients in 31 smaller hospitals "remote stations".  Training
              programs are included for physicians, nurses, and allied health
              personnel.

              Achievements: (The project was funded only as  a  feasibility  study
                            at approximately @ the original request) By the
              end of 1970, 17 remote coronary care beds located in 12 small
              community hospitals were being monitored by trained personnel   in
              6 central monitoring hospitals.  By November 5, 1970, a total   of
              303 patients had been  remotely  monitored.  Preliminary  statistical
              results indicate reduced mortality rates can  be  expected.  By  the
              end of the current operational year 40 to 43 remote beds will be
              operational.

              Future Plans: One year renewed support is being  requested  in  this
                            application.

         Cancer
        Project #5 - A Cancer.Control Program for the Tulsa Area

              Funded Period: 5/69-5/71
                             Ol-$70,000    02-$50,000  (approved for 03 year)

              Objectives: The project proposed a series  of  activities  including
                         screening of the disadvantaged population in Tulsa
              coordinated city-wide tumor registry system, coordinated continuing
              education among the three hospitals, and rehabilitation.

              Achievements: The project has served as a catalytic  agent  to  involve
                           numerous agencies in the problem of cancer.  The
              computerized tumor registry has succeeded in  providing  f6edback  on
              patients to their physicians.  Specific  patient  screening  procedures
              have been established to the point where with  the  additional  $50,000
              from Model Cities, 10% of the North Tulsa  Target  Area,  population
              over 40 will be screened for cancer in the  coming  year.  Areas  of
              agreement have been achi6ved among Tulsa hospitals on acceptance
              of indigent patients generated by the North Tulsa Clinic.

              Fut ure Plans: Committed support for the 03  year  is  being  requested
                           in this application.

       Project #8 - A Regional Program To Promote Ea@_R@n@sL@.of lireast
                    .Cancer with @ i@a@-mE a@s s on.Mammography      Oklahoma
                     Medical Center


              Fiinded Period-. 5/69-5/71.
                            Ol-$loo,ooo          02-$100,000 (approved for  03  vear)

              L)@j_@t-ives : To establish a Regional Mammography [Jnit at  the  Medical
                         Center which would serve as a focal point for perfecting
              techniques and training personnel to develop other units within
              the Region. Evaluation of the capacity of  8pecially  toward  nurses




        Oklahoma Regional.                                      Rm 23-03        5!71
        me4ical Program


              to perform physicial examinations of the breast  and  mammography
              screening was planned.  A training program for radiological reside  nts
              .in mammography was to be instituted the 3rd year.  Mass  mammography
              screening was to be initiated utilizing a mobile unit.

              Achievements:  A mammography unit has been established at the Medical
                             Center and by the end of the 02  year,nine  outside
              areas will be doing mammography on a varying scale.     Radiologic
              residents are being trained with regular rotation through the
              mammography unit.  A program has been instituted for training
              radiologic technicians. All woment who are over 35  years  of  age
              are routinely scheduled for mammography.  Training of state
              physicians is conducted through the medical journals, films,
              exhibits and posters.

              Future Plans:  Committed support for the 03 year is  being  requested
                             in this application.

        Project #10    Regional Urology Program with Initial Emphasis  on  Cancer
                       of the Prostate  - Oklahoma Medical Center


              Funded Period:  .5/69-5/71
                              Ol-$75,000      02-$79,400 (approved for the 03 year)

              Objectives: Create a consortium of 13 urologists, each of  whom  would
                          coordinate project activities within his own subregion
              and to appraise local facilities, resources, manpower  and  medical
              practices as they relate to the diagnosis and treatment  of  cancer
              of the prostate. Analysis of hospital records and  tumor  registries-
              with follow-up on all cases was planned to identify the  local  needs
              for continuing education.

              Achievements: With the support of the Oklahoma State  Urolcigical
                            Association a summar pre-test with  eleven  medical
              students was completed using protocol forms designed  for  computer
              analysis. The material representing over 900  clinical  cases  plus
              mortality data inditated the feasibility and value of such a
              regional project.  The permanent field staff of registered
              nurses who were trained in abstracting information  from  records,
              made contact with each of their  subregional  hospitals.  A'total
              of,2,264 cases, of cancer of the prostate were identified in
              220 hospitals.  Evaluation is being made of six representative
              groups of different urologic care settings in the Region.  The
              number will represent approximately a 15% sampling of  the  total
              2,262 cases.

              Future Plans: Committed support is being requested in this application
                            for the 03 year of operation.





         Oklahoma Regional                     -1.9-                 2@-r)?        5171
         @let-lical Program


         Related Diseases

         Project #3 - A Regional Emphysema Program     Oklahoma Medical Center

               Funded Period: 5/69-5/71
                              Ol-$150,145       02-$142,145
                   t@ L@,s: A Regional Emphysema Unit would be established at  the
                           Medical Center and would serve teaching and
               demonstration purposes.  It would be available as a consultative
               and educational resource to  community  hospitals.  Improved  patient
               care would be achieved by recruiting and training personnel, developing
               continuing education programs, establishing collaborative
               relationships, improving and expanding screening activities.

               Achievements: Three new pulmonary disease specialists have been
                             recruited into the state to fill key hospital
               teaching positions in affiliated  hospitals.  Three  model  intensive
               respiratory care units have been established  (Oklahoma  City,  Tulsa
               and Stillwater) and serve as intensive training units.  A screening
               program employing spirometry is being employed at the Medical Center.
               Education and Training is carried out through model units, clinics,
               workships and seminars, over 1,700 health professionals  ave
               participated.
                                           ort is being requested in this application
               Future Plans:  Renewed supp
                              for a 3rd year of operation.
         Project #9 - @@c @opA.1 P      am  I  Nu                       Okl.alioma
                       Medical Center

               Funded.Period: 5/69-5/71
                              Ol-$29,000               02-$29,000
               qb    iv6es: To Improve the care of diabetic  patients  by  improving
                           the quality and quantity of  services  at  the  community
               level and to improve the quality and quantity of nutrition services
               in hospitals and nursing homes, emphasizing patients having
               categorical diseases.  The goals would be achieved through a
               series of continuing education courses for physicians, nurses
               and dieticians.
               Achievements: Seventy-seven people were recruited  and  trained  as
                              food service supervisors and will serve  in  smaller
               hospitals of sparsely populated areas.  An extensive program of
               continuing education was carrie(i out for professional,  dietitians
               an(i supporting @ieAl.tti-related I)L-rsoiinel.  'I'Iiirty workshops w(@rf@
                          it 1) (liff(,rt@nt locations, Itivo.1-ving 2,000
               Health work(trfi Ji) 15,000 education Hours.





        (r,inlioms Regional
                                         -20-                   RM 2'4-01        5171
        @,tc,rlical ProRi-anis



              Future Plans:  Terminating  A plan has been developed to exploit
                            the progress to date with a new 3-year program, a
              majority of which would be financed by cooperating groups other
              than OR@IP.





        Project #4    Continuing Education for the Enid Area    St. Mary's
                      Hospital

              Funded Period: 5/69-5/71
                              oi-$35,000              02-$41,000 (approved  as a
                                                                   renewal for an 03
                                                                   year-but unfunded)

              Objectives: A prototype "medical education center" would be established.
                          The surrounding counties with eight participating
              hospitals would be included.  Continuing education modalities wou
              include video-tape, and 10-tape, library resources, self-instructional
              material films, conference-type telephone communications, and short
              courses.  The project seeks to demonstrate the feasibility of
              such a subregional  center" and hopes to. develop a network of similar
              centers

              Achievf--ments: I)uring a fotjrt(!en-rj)ontli I)e'riod, 55 pliysiciiiis' tele-
                            conferences have been conducted.  Out of 150
              physicians  in the area, an average of 46 participated in each conference.
              A total of  10 day-long physicians' seminars-were held with an average
              of 22 participants.  Dial access tapes have held for nurses,-IO
              for laboratory technologists and 3 for dietitians.   Sixteen seminars
              were held for nurses.

              Future Plans: This project has previously been approved as a renewal
                            (4R) and support is being requested in this application.

        Project #6 - Library and Information Services - Oklahoma Medical Center

              Funded  Period:  5/69-5/71
                              oi-$49,000       02-$49,000 (approved for 03 year support)


              Objectives:  Through the Medical Center f,ibrary, this project
                           seeks to improve library information services by
              increasing the speed of delivery, and Improving the relevance of
              the Lnformatidn retrieved.  The program wil.l. be expanded to
              three model programs involving five hospitals in Oklalionil
              (,ity, 'ftilsa and Eni(l. 'I'he program would promote knowledge of the
              improved library facilities among the medical community.





          Oklahoma R(,@,ional                                     Pm 2@-O'A       5 /71
          M,Pfliral P,oi,,,-arn.@


               At-lij(--v(-iiienLs: Etciiis of information being sent out have increased
                             from 500 per month in Jantiary 1970 to 900 per month
               in November 1970.  flealth professionals using the service tend to
               come back.  Workships are conducted to train part-time individuals
               in change of hospital libraries throughout the state, 96 have attende-.'
               to date.  Cooperative relationships with other hospitals have been
               strengthened.
               Future Plans:  Request is being made in this application for
                              03 year committed support.
         Project #7 - Regional Program of Public EducatLan on Smoking and Health

               Funded Period: 5/69-5/71,(Under Core)
                              Ol-$12,00    02-$24,500

                           This project would merge the efforts of ORMP and the
                           Interagency Council on Smoking and Health.  ORMP
               would support a coordinator and the Council would support necessary
               staff.

               Achievements: Anti-smoking messages have been publicized through
                           I  printed material, radio, television, speakers bureaus,
               exhibits, etc.



















                                                                                                                                                        y I
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                                                                                                                                                              C2- 3

                                                                                            PROP054LS
                                                                                          R-IPIAL ORAPR




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           Oklahoma Regional
           Medical Programs                         -23-                     RM 23-03        5/71

           summary of operational projects currently bein& supported by Oklahoma/Rl4P

                                                                         Funded 2nd Year d.c.
           Project Title and                                              (5/l/70-4/30/71)
           #1 - CORE                                                           $     360,000
           #2 - A Coronary Care Program for Oklahoma                                 199,600
           #3  -  A  Regional  Emphysema  Program   for   Oklahoma                   142,145
           #4 - Continuing Education Program for the Enid Area                      41,,OOO
           #5  - A Cancer Control Program for the Tulsa Area                        50,000

           #6  - A  Regional  Program  to  Improve   Library   and
                 Information Services                                               49,000

           #7  - A  Regional  Program  of  Public   Education   on
                 Smoking and Health (Core activity)                                 24,500
           #8  - A Regional Program to Prowte Early Diagnosis
                 of  Breast  Cancer  with  Special   Emphasis   on
                 Mammography                                                         100,000
           #9  - A Regional Program in Nutrition                                    29,000
         #10   - Regional Urology Program with Initial Emphasis
                 on Canter of the Prostate                                          79,400

                                1--month                    Projects                57,512
                               extension
                          (5/l/70-5/31/70)                    Core                  30,000

                                                                 TOTAL            $1,162,157



           Al] of the operational projects submitted by the Region were approved
           and are currently funded.





                         DEP,KRTMENT OF HEALTH, EDUCATION, AND WE
                                                                   LrARE
                                        PU13LIC ii@NLTH SERVICE
                           HEALTti SERVICES AND MENTAL t-IEAL,rH ADNIlt4lS'fFIATIOrl


       Date:,,March 30, 1971
      &-ply to
      Atin o
          .f.                                            I
      Stfbjecti Staff Review of Non-Competing Continuation Application from  Oklahoma
              Regional Medical Program, 5 G03 - RM 00023.
         To:
            Directo
                   r
            Regional@edical Programs Service

            THROUGII: Chairman of the Month/\,)
                                           @Z)
                      Chie -,,G-r'ants Review Branch

                      Chief, Grants Management BranCn

                      Acting Chief, Regional Development Branci

            RECO114ENDATIONS:

            1. The Region not be considered for three-year support at this time
                but that  PITS offer extensive assistance to the Region in
                preparation for resubmission next year.

            24  The'Region be awarded the new funding level of $738,500 for its
                third year of operation, to continue Core and Projects #5,#6,#8,#10.

            3.  That the Region be enco raged to rebudget into core as seen fit,
                                       14
                to advance its program planning to correspond more with new
                philosophies, and to identify needs, objectives and projects  more
                specifically and in terms of a total program.

            4.  In line with the first recommendation, a site visit team, including
                a Committee and/or a Council member, or other persons of equal clout,
                visit the Region as soon as possible, preferably before the end of
                July, in order to provide much needed cuidance in the areas of;
                the new and broadened philosophy of Rig, assessment of needs, establish-
                ment of objectives., and program evaluation.

            Staff sees this as a critical need for the Region in  preparation  for
            resubmission of a Triennium Application next year.

                EST: Oklahoma  Regional@ Medical Program which is in this 02
                      operational year (5/l/70-5/31/71) has submitted a  Triennium
            Application consisting of:

                I  A Developmental Component
               II -The Continuation of Core and Four Projects
              III -The Activation. of One Coi-incil-,-Aoproved but Unfunded Activity
               IV -The Renewal of Two Activities
                V -The Implementation of Six Nei,7 Activities
               VI -The Termination of Two Activiti.cs





           The consolidated budaet requests for each of the three years are as follows
            (direct costs)
                                 3rd Year      4th Year      5th   Year   TOTAL
           Core                   $645,769      $664,277       $690,539   $2,000,585
           Projects             $1,304,796       824,440        662,220    2,791,456
           D6velopmental            70,000        70,000         70,000      210,000
                TOTAL           $2,020,565    $1,558,717    @l,A22,7510   $5,002,041

           Oklahoma  RMP, when annualized, is currently being supported in its '02
           year at  $360,000  (d.c.)  for  Core,  $24,500  (d.c.)  for  stoking  and  health
           -activities  under  Core  and  $690,145  (d.c.)  for  eight  projects,  totaling
           $1,050,145  (d.c.).  It  has  a  commitment  of  $839,205  for  Core   ($360,000)
           and Projects #5,#6,#8,#10 ($479,ZO5).

           REVIEW: The Region has chosen to request triennium support now, at
                    the conclusion  of  their  02  year,  rather  than  wait  an  additional
           year and  request  triennium  support  at  the  end  of  their  03  year.  Since
           the region is not  scheduled  for  a  site  visit,  it  will  be  necessary  for
           Committee and Council to  make  a  general  assessment--  of  the  program  based
           entirely on the application.

           Staff agreed the function of their review should be to make observations
           and recommendations to be referred to Committee and Council.

           OBSERVATIONS: The overall program goals and objectives remains basically
                           the same as those established for the first three years of
           operation.  They are largely oriented toward education and training
           activities, and are vague, non-specific and immeasurable.  They do
           not appear to be based on-specifically assessed needs nor do they
           relate to identifiable time-frames.  They are so broad and general-           so
           as to be:applicable to any type of educational project.

           The functions of the Steering Committee, are unclear especially its
           relationships to the RAG in policy-making and development of goals.
           It  is  difficult  to  seethe  need  for  13  different  categorical  committees
           in a Region having  the  limited  activities  of  Okl.ahoma  and  there  is  some
           question as  to  the  degree  of  their  involvement.  While  it  appears  some.
           of these committees have promoted the development of particular projects,
           there is no evidence that those projects relate to an overall. Dte--established
           specific design or set of objectives.  @ather, the projects appear to
           be generated on a random basis.  One exc&ption is the continuing education
           program  designed  to  develop  continuing  education  centers  in   more
           rural communities.

           The  review  process  appears  functional  in  that  criteria  are   established
           for technical review by both categorical committees, and the.RAG.
           While the RAG also reviews projects as to their relationship to the
           overall  objectives this process appears superficial, in that, the objectives
           encompass  such  a  broad  spectrum  practically  any  education  type   project
           will. qualify.  There appears to be established procedures for Staff
           monitoring of ongoing projects and in addendum material there is evidence
           of relative effectiveness.
           Core  as  organized  is  highly  ori.ented-towai:d  educational  activities  and
           categorical diseases as is the- overall prog-raio.. a fact which. staff believes
           reflects  on  the  progressiveness  of  this  Region.  It  appears  the   Region




            Director,RMPS   Page 3.

            is not taking into consideration new trends within RM-@DS- and
            has not broadened the scope of its program, nor its core  staff,  along
            the 14 nes of the,newphilosophies.  Staff expressed concern based on
           ,this observation that,whi.le the organization of Core as proposed might
            have been appropriate for  the  progr.am-a year ago, it may not be
            desirable for the, future and that having once adopted the proposed
            organization pattern it would be inflexible or  awkward-to  change.
            It was noted that since this Region's last visit in November 1968, Core has
            been reorganized twice.

            The problem of acquiring an M.D. as Associate Goordi.nator no longer
            exists, in that the position has-been eliminated.  Staff, recalling
            the recommendation of the staff members who visited the  Region  in
            July, 1970 and felt this position to be of-extreme  iniportance.and needed
            to be filled as soon as possible, expressed concern over  this  new
            development.  In the past the responsibilities of this position
            have to a large degree fallen to the Assistant Director, a non-phvsician,
            who subsequently became overburdened with work.  Under the new organizational
            plan it appears this situation will be perpetuated.  In addition, Staff
            questioned whether the-Assistant Director should in fact be the Chairman
            of the Counril.on Planning, Review and Evaluation.

            With the development of only three subregional.planning  groups,  Staff
            believed the RAG members should be encouraged to take the lead.in-
            developing similar groups in their respective communities.

            In view of the above observations and the fact the Region is -not
            to be site visited, Staff concluded O@ should  not  be  considered  for
            Triennium Review at this time but rather that R-MPS offer extensive
            assistance.to the Region in preparation for another attempt next yeAr4





                                       William S. Reist
                                       Public Health Advisor
                                       Grants Review Branch
                                       Regional Medical Programs  Service



            Act
            Dat
            Sig

                       Participants in the Oklahoma Type V were as follows:

                       Leah Resnick-Regional Development Branch
                       Margaret Hulburt - Allied Health Section
                      'Joan Ensor - Program Planning And Evaluation
                       Frank Zizl@avsky - Regional Development Branch
                       Rod Mercker   Grants Management Branch
                       Judy Silsbee   Grants Review Branch
                       Bill Reist - Grants Review Branch



                                                                           GRB/RMPS









                              SU'eiYjARY OF 'PEVIEI,,7 AND CCr@:,iCT,USI@4 OF
                                                        r
                                   A@DRI-r@ 10@71. 11,EVIEW CO@@,-"T"4'--E


                               O@HO',,IA ItEGIOI-'i'l@L L@IEDICAL PROCRAti
                                       RI@l 00023-@")3  5/71


                        FOR CONSIDEPAT107;.,T BY @IAY 1971- ADVTSORY COLTNCIT,



           RECOi@2' NI)ATT(riIS:


                 Year       Reouest. (Direct Cost[,)__    Recof,,tne@ on  D@@@Cat@

                  03               $2,020,565                       $913,500
                  04                1,558,717
                  05                1,422,7.59


                    TOTAL          $5,002,041                       $913,500


                 1.  Approval of committed support  ($738$500  direct cost ) for
                     Continuation of Core and projects Y,@5, 6, 8, 10, fGr the
                     05  car. I/
                        y

                 2'.'. Approval of Project Y@2R, at a reduced level. of $175,000,
                     (d4-rect costs).

                 3.  Approval of rene,@ial project -@,3R and. si;@ iir---@7 projt-,ct,.,
                     18, without additional fxint7ts,

                 4.  Non-approval of the Develo-,,)ina-titol

                 5@  A site visit be      to the Region -Lr) order tc detf-@riii,'-tie
                     its current status, to studA?             atianl- care of
                                                  _effects or..     L
                     ongoin.c, activities 1),irticiilarl-y its c@incei.. and respiratory
                     disease areas  and to provide cij3'.dancc@ to I-lic-- Region for
                                   $
                                   of a tri.eii,-Li'LitrTi


              Cor,,arittec concurred with Slk--aff s recoriiriencl,-@,tici-ii, from its pro iniiii,.iry
               rex,icT,7,, tl@dnt the Region be :-,,-,;@roved for committee sul@Cort.


           a! r@q!Eb:  Whi@le the application ns           by OPTIP i3     pre@,ented
                       on p@-it)rr, Committfc,, in the ,ib,,;ence of @,. cited. visit, hard
                      abott x,?Ii-ot is really hip,@?crLing l@ii trip PQgioii, p4,ricul..nrly in
           view of the             observctti.r)ns,





              OKlAliOi4A RYIP                        -2-                             PIM 00023


              The goals and objectives were considered v@l-u@-, nonspecific and
              immeasurable..  They  do  not  appear  to  be   based   on   specifically   assessed
              needs,  nor;do  they  relate  to   identifiable   time   frames,   Together   NYith
              the  projects,  the  goal.s  and  objectives  being   proposed   represent   a
              program  highly  oriented  toNiard   education   and   training,   activities   which
              are  not  consistent  with  current  R-I,IP  trends.  There  does  not   appear
              to be an effort  to  stimulate  projects  @,?hich  rf-@l.@ite  specifically  to
              objectives  rather  projects  ippear   to   be   spontaneously   generated   on   a
              random  b-.sis-and  only   coincidentally   relate   to   stated   objectives.

              The  functions  of  the  Steering  Crir@riiittee  qre  unclear,  especially   its
              relationships to the  11,AG  in  policy  making  and  etevelol)nil-nt  of  goals.
              The reviei,,ers v.
                                ere  not  convinced   the   proposed   orgaiiizntion   of-Core-
              Staff v@6uld be  appropriate  for  the  future.  l@Totiiig  tbnt  R'EIPS  Staff
              had  concerns  about  the  Coordlilitor,   Associate   Coordinator   and   tie
              Assistant Coordinator Positions,  their  rejpoiisi-bilit_..j.es  Ind  x,7ork  loleis,
              Cor@,niittee  believed  these  concerns  should  be  clarified  prior   to   approval
              of a Triennium Application.

              In  the  absence  of  more  than  three  subregional  pl.anning  groups,  it  x.;ns
              difficult for Committee to understand  ti-ie  itivol-veitir@iit  of  the  more
              rural coinmu-Liities.

              Vlhile projects  Here  not  reviei-7ed  in  detail,  some  concern  i-7as  expressed
              over the cancer and respiratory disease aspects of the program.
              Disappbibttneiit  was  expressed  over  the  progress  of  the   Tulsa   Cancer
              Program, v7l-ii.le the Er-iiphyse-,iii Program nprears  highly  over  budgeted.
              Although Project fr2R      Co onary Cpre Prn-@             tv  to   have   progressed
                                       -    Eo                 @l!] appen
              at  a  satisfactory  rate  and  i;arrenL@s  additional.  support,   Committee   did
              not feel EMPS shoul-d be providing support for large purc'neses of
                            Iti  therefore,  recommends   additional.   support   for   this
              project  be  limited  to  $175,000.  Also   the   apparent   absence   of   financial
              contribution  by  the  Indian  Health   Service   to   the   Regional   Pediatric
              r@ @am (Project #13) was questioned.


              The Re-gion's rel.atioilrbi@, illith the 14e(lic@,l School is unclear    qnd   some
              question i-7as raised as to i;l-iethc.@r 011,1,,'P is being used.

              Committee  concluded  that  many  of  the  areas  around  @-Aiich   concern   was
              expressed  are  basic  to  the  functions  of  t  viable  RMP.  In   view   of
              this, Committee agreed  with  R@IPS  Staff  that  the  Region  has  N-71-iat  appears
              to be  some  serious  weaknesses,  viiiiclt  need  to  be  rectified  prior  to  the
              re-submission of a Triennium Application ne,ct year,  It 1,7aS proposed
              a site visit  be  made  to  the  Region  in  the  near  fottire  to  obtain  a
              better understanding of the Region and provide needed guidance,                    -







                                                                            C.RB/Rl@IPS/4/23/71













                                  REGIONAL MEDICAL PROGRAM SERVICE
                      SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION
                                      (A Privileged Communication)


             PUERTO RICO REGIONAL MEDICAL PROGRAM               RM 00065 5/71
             Post Office Box M.R.                               April 1911 Review Committee
             Caparra Heights Station
             Puerto Rico  00922

             PROGRAM COORDINATOR:  Cristino Colon  M.D.


             This region, currently in its first year of operation, is funded at a
             level of $958,163 direct costs.  In addition the region has received
             $112,414 of indirect costs which represents an average lndi tect cost
             rate of 28.6 percent.

             In this anniversary application the region has requested for its second
             year of operation $1,136,564 d.c. for support of the following Activities:

                             1.  The continuation of Core and seven ongoing
                                projects ($958,163).

                            II.  The implementation of two new projects ($82,953).

                          III.  A Developmental Component  ($95,,.448).

             (Attached on the back of the summary is a chart identifying the
             components Involved with the above items.)
             Following,are the key Issues identified by staff in their review of the
             continuation application.

                      1.  The need for  better geographical representation, lower
                          economic consumer and Model Cities program representation
                          on the RAG.
                      2.  The need for RAG to assume leadership and give direction
                          to the PR-RMP.
                      3.  The increase of Core from 29 to 44 positions.
                      4.  The expansion of Task Forces to include allied 'health
                          personnel.
                      5.  The lack of interrelationship between the task forces, RAG,
                          Planning Committee and Core.
             (Attached on the back of the summary is a copy of the memorandum of staff's
              review of the continuation application.)




           Puerto Rico RMP                          2 -            RM 00065  5/71
                                     FUNDING HISTORY (Direct Costs Oni
           Grant Year                       Period                       Funded

           Planning, Stage
                01                       6/l/68 -   5/31/69              :$194,839
                02                       6/i/69 -   5/31/70                194,097
                02 S                     6/i/69 -   5/31/70                 94@281

           Operational  Stag
                01                       3/l/70    2/28/71      Core      $320,081
                                                            Projects     638  o@82
                                                               Total      $958,163


           GEOC,RAPHY  AND  DEMOGRAPHY
           Puerto Rico, the easternmost of the Creater Antilles, and fourth
           largest island in the Caribbean area, is bounded on the north by the
           Atlantic Ocean and on the south  by  the  Caribbean  Sea.  The  Capital
           city, SAn..Juaft, lies some 1,690 miles southeast of   New York City
           and'1000miles southeast of Miami.  The island of 3,435 square miles,
           roughly 100 miles long by 35 miles wide, is characterized by a
           fertile coastal plain covering about 1/4  of  the  land  area,  and  an
           east-west  running   range of mountains.  Two of the three larger   out-
           lying islands are constituted as municipal governments.  Rivers
           are  numerous,  though  of no importance in navigation.
           The  northern  coast,  due to prevailing winds, has an abundant rainfall,
           the same  as  the  central mountain range, with peaks above 1,000 meters.
           In contrast, the southern coast is rather arid, traditionally depending
           on irrigation of single crops.  Sugar cane, coffee, tobacco, green and
           starch vegetables and fruits, mainly citrons and pineapple are the
           principal crops grown.on 56% of the land that is tillable.
           Population:  1970 estimate - 2,947.

                Approximately 51% urban
                Median age:  19.71 years. (U.S.   average 29..5 yr.s.)
                Density:  760 per square mile

           Land Area:  3,435 square miles

           Health Statistics:
                Mortality rate for heart disease - 147.9/100,000 (low).
                Rate for cancer - 88.4/100,000 (low)
                Rate for CNS vascular lesions - 56.4/100,000 (low)

           Facilities Statistics:
                University of Puerto Rico School of Medicine - 4 year school,
                enrollment of about 301.





           Puerto Rico RMP                           3 -           RM 00065 5/71


                University of Puerto Rico School of Public Health  -  accredited,
                enrollment approximately:  384.

                10 schools of nursing, 7 are at hospitals, 3 at colleges or
                universities (2 of them are degree programs).
                Two schools of medical technology (Department of Health,
                Institute of Health Laboratories and the University  of  Puerto
                Rico School of Medicine) one school of cytotechftology.
                138 hospitals in Puerto Rico with 11,872 beds (49  private,  58
                Puerto Rico Health Department, 31 municipal)

            Personnel Statistics:
                2,791 physicians (approximately 1/1000 populat ion)
                4,400 graduate nurses (approximate)
            The economy has shifted from agriculture to a more diversified base.
            An idea of increasing diversity of manufacturing may  be  gathered  from
            the fact that manufacture of sugar products  represents  4.9  percent
            of manufacturing income compared to 35 percent in 1940.
            Tourism is a steadily growing  sector of the economy, with total relate
            income cost reaching around $155 million.
            The Puerto Rican people have benefitted greatly from.the aforementioned
            expansion achieved since 1940. Life expectancy  has  increased  from  46
            years to 70 years And the crude death rate has declined  from  18.2  per
            thousand to 6.5 per thousand, somewhat less than  the  U.S.  average.
            In Puerto Rico there are still two systems whereby  the  population
            utilizes health tare services;-the private and the  public  or  govermentIal
            systems.  It is estimated that 40% of the population utilize private
            medical and hotpital services and 60% utilize the  public  serv  ces.
            Between3O'/. and 40% of the population is covered by some type of  health
            insurance. An unknown proportion of  the  population  uses  private
            sIervices at times and public services at other times, depending
            basically on its economic conditions at the time and on  the  nature  of
            the illness involved.
            About 41.4% of the general hospital beds in the  island  are  located
            in private hospitals. Of these, 17.2%  are  in  private  non-profit
            hospitals and 24.2% in private proprietary hospitals.  Most private
            proprietary hospitals are owned and  operated  by  physicians.  The
            private hospitals for the most part are located in  the  main  cities
            San Juan, Ponce, Mayaguez and Humacao.  Private hospitals serve, not
            only the population in the municipality where they are located, but
            also receive patients from neighboring municipalities.
            The public medical and hospital services are  administered  by  the
            Puerto Rico Department of Health, the  municipal governments and




           Puerto Rico RMP                         4 -            RM 00065 5/71
           other state Agencies, i.e.,(Workmen's.Compensation),.  Basically,.the,,
           municipalities have the main responsibility for the. provision of health
           care to the needy.  There are seventy-five municipalities ranging in
           size from 7,000 to- 500,000.  The Commonwealth Governments, however,
           complements the municipal care system.  Through arrangements and
           agreements with-local governments, public health services - preventive
           and curative   have been organized into a  single system operated jointly
           by the Department of Health and Municipal Governments.; the Department
           assuming full responsibility for technical And professional service. in
           practically all municipalities, except San Juan.
           In each municipality, there is A.health center.  It inciudes,a hospital
           unit (usually one bed per 1,000 inhabitants),  general  out-patient
           facilities and the public welfare unit.  In 45 of the 75 municipalities
           ad hoc buildings have been erected to house these health'and social
           welfare facilities.
           A regionalized program of medical care developed over the past ten
           years has resulted in the development of nearly 80 regional health
           centers and community hospitals,.and the formation of five  regional
           health districts., to be condensed to three major areas (northeast.-
           south, and.west)

           HISTORY
           In September, 1967, Dr. Nigaglioni, Chancellor of the Medical Science
           Campus, University of Puerto Rico convened a meeting of leading Health
           Profes sionals in Puerto Rico to determine appropriate steps for
           implementing PL 89-239 in Puerto Rico. This  group  was  designated
           the "Planning.Committee." A 20-member Regional Advisory Group was
           formed and a planning grant application was, developed for submission.
           On October  1967, the Regional Advisory Group (RAG) at its first meeting
           elected Dr. Adan Nigaglioni, Program Coordinator and  approved  the
           Medical Sciences Campus, University of Puerto Rico as the applicant
           institutions.  The initial planning grant.wa,s submitted to RMPS on
           December  1967, requesting two years support for planning.
           At the recommendation of the RMPS Review Committee a site visit was
           conducted to this region in April  1968, by Dr. David E. Rogers,
           Dr. Henry Lemon, Dr. John R. Hamilton, DRMP and Mrs. Jessie Salazar, DRMP.
           During this phase of development, there appeared to be a lack of supporting
           data from private medical areas, as well as evidence of involvement of
           some of the key public health personnel.  Further, it was pointed out
           that the.RAG could be strengthened by the addition of lay members.
           Council believed that there was no substitute for a full-time person
           who would be responsible for these RMP activities.  This did not imply
           lack of confidence in the Chancellor, who was the Program Coordinator,
           but rather believed it imperative for the future program to have at
           least one person who would devote all of his professional time to it.
           On the basis of this recommendation, Dr. Cristino Colon was appointed
           full-time Associate Coordinator in August 1968.




            Puerto Rico RMP                         - 5 -              RM  00065  5/71

            In May 1968, the planning  grant  application  was  approved  for  two  years
            with  the  recommendations:  greater  involvement  of  medical  societies;
            and recruitment of a full-time Deputy Coordinator.

            In June  1969, the region's continuation planning grant was approved.
            Staff noted that the region had progressed noticeably since Dr. Colon
            became Associate Coordinator of the program.    In addition to committed
            funds, the region was given  a  one-year  award  with  unexpended  funds  for
            two activities: special  studies  to  assemble  new  data;  and  to  organize
            and implement an office of Information and Public Relations.  The
            region's plans were to merge these two functions into the Core activities
            when it went into operational status.  In regard to the region's progress,
            staff believed the  evaluative  process  to  be  weak.  The  categorical
            Task Forces were named and functional, and  there  appeared  to  be  a  trend
            toward decentralization with established Committees outside the San Juan
            Area.

            In  August  1969,the  region  submitted  its  first  operational  application
            requesting support for  Core  and  8  projects.  A  preoperational  site
            visit was conducted in September 1969, by Dr. B.W. Everist, NAC,
            Dr. Henry Lemon, R.C4, Dr. Henry Clark, Consultant, Mrs. Jessie Salazar,
            RM-PS, GRB, and Mr. Frank Nash, RMPS, RDB.
            Major developments in the  health  care  field  reported  during  this  phase
            of the program involved Puerto Rico  embarking  on  a  new  and  ambitious
            program to integrate  the  private  and  public  sectors  of  medicine.  This
            was instigated with the passage by  the  legislature  of  PL  56,  permitting
            payment for services of private patients in Health Department Hospitals,
            and for indigent patients in private hospitals.  Out-patient cost
            reimbursement is also  included.  Under  PL  81,  approved  May  1967,  seven
            experiments in five  different  towns,  with  different  alternatives  for
            financing health care were initiated in an attempt to develop A
            unified group practice in community health centers.
            In view of these developments the  NAC  recommended  to  the  region  that
            a Special Task Force be  organized  to  work  with  the  Commonwealth  Health
            ,Departmento the University Medical  Center,  the  Puerto  Rico  Medical
            Association, and the voluntary  health  agencies  to  make  an  extended
            evaluation of progress in the methods of solving primary medical care
            problems under study.
            The NAC believed that the RAG was  still  heavily  oriented  to  the  Medical
            School, although the region indicated  that  the  size  of  the  Group  would
            be increased.  The region was urged to expand its representation from
            the private medical sector, and explore the possibilities of representation
            from the new industries located on  the  island  to  participate  in  medical
            care planning to avoid dislocations between needs and services.  The region
            reported that general by-laws have been adapted and administrative guide-
            lines for Task Forces were under development.
            In January 1970,  the  region  received  its  initial  operational  awat  for
            support of core and six projects.




           Puerto Rico RMP                       6   -             RM 00065 5/71
           The region submitted in July 1970, an application requesting support
           of three new activities   The Review Committee recommended a site
           visit to the region which was conducted in May 1970, by Dr. Henry  Lemon,
           RC, Dr. William S. Fields,  Consultant,  MrI9. Jessie F., Salazar, GRB,
           and Mr. Frank Nash, RDB.
           The region was just beginning to move into full  operational status,
           and was continuing to refine its organizational  framework under t e
           leadership of Dr. Cristino Colon, who appeared to be doing an ef f ective
           ob.  Planning for RMP program outreach beyond the San Juan medical area
           had been achieved.  The Council indicated that  they were impressed by
           the development of major interest and enthusiasm of lay and medical
           leadership in Guaynabo, Ponce, and to a lesser extent, in Guayama.
           Dr. Nigaglioni, the official Coordinator, appeared to be  more  and  more
           a background figure, but very valuable for his 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.C.   members  and
           sub-committee members was still insufficient.  The private   medical
           sector in San Juan appeared inactive in planning or participation.
           industrial medical facilities developing at the Phillips  plant  and  the
           Chem-strand plant at Guayama appeared to be outside of RMP planning
           efforts. In Ponce, on the other hand,  there  was  excellent  lay  liaison
           through the Oncologic Clinic, supported by the southern branch of
                       Society,
           P.R. Cancer          and through Dr. Rodriguez's cardiovascular and
           renal dialysis and transplant program which  has  wide  and  enthusiastic
           public support (750t'r dialyses for 35-40 patients in the past two years).
           The excellent private medical sector support and participation in. Ponce
           district projects is quite different from the Capital  Area  indifference
           and bodes well for effective RMP projects in this a  rea.
           The nursing profession is still being slighted as an ally in health
           planning, in traineeships,  and in operational programs  as  instructors.
           The Council cited the desirability  of  broadening  operational  programs
           to effect a multidisciplinary approach particularly in training activities.
           Council also believed that a ceiling already has been reached in the
           50 - 100% participation of physic ians for leadership and development of
           programs.  Future site visitors must carefully evaluate whether salaried
           time on the job in RMP programs is really being effectively applied
           by named participants.
           Council recommended new funding for all three of the activities proposed,
           however, because of present RMPS fiscal restrictions the region was
           granted a reduced award for support of Project #10,- Family Prevention
           Program on Stroke.
           The region submitted to the November 1970. Advisory Council an  application
           requesting new funds for support of two new activities.  Additional
           funding was recommended by Council at a reduced  level,  but  because  of
           existing RMPS fiscal restraints no additional funds were awarded.





           Puerto Rico R)4P                  -7-                          RM 00065 5/71

           PRESENT APPLICATION

           This is an anniversary application in which the PR/RMP has requested
           continuation support in 02 operational year for Core and seven ongoing
           projects, and new funding for a Developmental Component and two new projects.

           CORE  STAFF

           The Core staff of the PR-RMP has been expanded from 29 to 44 positions with
           All but one employee at less than 100% time and effort.
           The organization of the Core staff is shown on Figure 1 and reflects a
           basic line/staff differentiation. The staff  functions  are  identified  as
           Administration, Biostatistics, Planning and  Public  Relations.  Tho  line
           functions are Education, Research and Service.  The Regional Office covers
           the three basic subregions of Mayaquez, Ponce and San Juan.

           The Region indicates that with problems in recruitment it was necessary to
           adjust the structure in order to carry the  program  forward.  Transfer  of
           personnel from staff to line functions provided temporary relief in the areas
           of research and services.  The region has accomplished this by adding eleven
           new positions to staff the subregions in Ponce and Mayaquez and hire per-
           sonnel for the Planning, Research and Evaluation Section  of  the  Central
           Core office. This was done within the present funding  level  for  Core  by
           utilizing funds available from vacant positions which the  region  has  had
           difficulty in recruiting. For the next grant  period  the  following  Core
           sections will work in the following activities.


                 Biostatistics Section
                 (1) Implementation  of the proposed Planning, Research and Evaluation.
                 (2) To implement at its maximum capacity the general system designed
                     for the evaluation of the different operational projects.
                 (3) lo continue updating the health personnel inventory in terms
                     of the more than 50 occupational categories included in our
                     files.
                 (4) To collaborate with the Research Section in  the  undertaking  of
                     studies channeled towards defining the scope, nature and
                     location of health problems and needs (to continue studies
                     of Puerto Rico as a medical care region).
                 (5) lo maintain a close working relationship with, among others,
                     the Comprehensive Health Planning Program and the School of
                     Public Health of the Medical Sciences Campus towards the
                     organization of greatly needed data bank, which  could  be  used
                     by any public or private health agency in the Island.

                 Health Services Section
                 (1) Terminate arrangements for the Neighborhood Pealth Center of
                     Loiza as soon as possible.
                 (2) Visit the Kaiser - Permanente (,rotip Practice and other  similar
                     groups in the IT.S. with the purpose of collecting as  much  data
                     as possible for the establishment of similar groups in P.R.





         Puerto Rico RMP                     -8-                    RM 00065 5/71

                (3)  Subs  ize a project to be carried out by a competent  legal  firm
                     on the legal aspects of group prac tice and doctors'  co   oration
                                                                            rp
                     in.P.,R.
                (4)  Continue evaluation of operational projects.
                (5)  Continue their contribution to development of the Global   Health
                     Plan for P.R. by Comprehensive Health Planning.

               .EdtcAtional Activities Section
                (1) The regionis planscontemplate  the  development of  a  continuing
                     education system which could eventually expand to cover the entire
                     region.  The proposed strateRv is re-create a series of
                     semi-autonomous sub-regional systems in the  different health
                     regions which could develop educational  activities  tailored  to
                     their own needs.  These sub-regional systems would be linke  to'
                     the Core staff which would provide supporting  services  such  as
                     professional consultation and technological resources.  The
                     recently submitted proposal for  training  general  practitioners
                     In the Western Health Region should allow  the  PR-RMP  to  test the
                     feasibility of the overall plan.  Development and evaluation
                                 osed project has been given high  priority  for  the
                     of this prop
                     calendar year 1971.
                (2) Development of new  types  of  sub-professional health   personnel,
                     .is another area of concern for the  Education Section.  The
                     "Stroke" project should provide valuable experience in this
                     field.  Its training program for family health workers was
                     scheduled to begin in January 1971.
                (3)  In the area of public health education it is planned to continue.
                     encouraging citize'n' participation in their own health  affairs.
                     The "Project for Education of Consumers in Health Care Planning"
                     in the Caguas Sub-region will serve as a demonstration area for
                     other groups created under the provisions-of title 314-B P.L. 89-749.
                     This project may also serve as a  continuing  education  activity
                     for health educators.
                     The project "Loiza Neighborhood  Health  Center"  would  be  the
                     first of its kind in Puerto Rico. it would provide a unique
                     experience in community health including its educational aspects.

                Public Relations Section
                     Several projects now in incipient stages will become ma or
                     centers of activity in coming months.  These- will include,
                     in addition to the devel opment of a "speech bureau":  the
                     assumption of leadership in the creation   of a Health Information
                     Council made up of representatives of  diverse  sectors  of  the
                     community; publication, in conjunction with the Education Section
                     of PR-RMP and other health agencies, o  a bimonthly calendar of
                     continuing education activities for distribution to all medical





          Puerto Rico RMP                    -9-                 RM 00065 5/71
                    and paramedical personnel on the island; as part of the establ4ls'n-
                    ment of a PR-RMP Library, the organization of an internal-
                    Center on Regional Medical Programs containing all available
                    non-technical material relating to RMP locally and nationally, for
                    the use of the Core staff, advisory groups and others.

                Planning Section
                    The Planning Section of the Puerto Rico  Regional Medical Program
                    was brought into being on August 3, 1970, when Constantino A-ivarez,
                    M.H.Se.Pl..,Ph.D., joined the Core staff.  As the Program's Planner,
                    Dr. Alvarez first familiarized himself with the organization and
                    began an evaluation.
                    As objectives for its first few.months of operation, the Planning
                    Section identified as objectives the drafting of a Master Plan,
                    and the involvement of Section heads and advisory groups in
                    the planning process and in the formulation of the Master Plan
                    itself.

                    Following his evaluation of the Puerto Rico Regional Medical
                    Program, the Planner presented the First EvaluAtive Report on
                    the Regional Medical Program from the Planning Viewpoint.
                    Further, he held orientation sessions with the rest of the
                    Core staff wherein he described the planning process and its
                    importance, and outlined the model to be followed in the
                    drawing up of the Master Plan.  (Brief description of Master
                    Planning-Section VI of application)


                    The predominant: activity of the Section was the actual  ra t ng
                    of the Master Plan in coordination with section heads, consultants
                    and task forces.

                    Additionally, the Planner has, on request, provided advice on
                    various planning matters to the Coordinator and the section heads.
                    Chief among the activities of the Planning Section for the coming
                    year is the implementation of the Master Plan.  The Planner will
                    also be required to assist the other section heads in the
                    formulation of their own individual long and short term programs,
                    and to help the task forces prepare their guidelines.
                    The two-year program of action for the Planning Section includes
                    a review of indications used in the preparation of the Master Plan
                    and the formulation of new indicators.  During the third and
                    fourth years, A revised Master Plan will be developed.

                Research Section

                    This section became operational on September 1, 1970,with the
                    appointment of Brian F. Mullan, a Health Services Researcher and
                    Institutional Planner.  Mr. Mullan, a Ph.D. candidate and full-
                    time employee, holds a joint appointment in the Medical Sciences






                                                                    RM 00065 5/71
         Puerto  Rico  RHP                  -10-

                                                                    is the parent
                     Campus of the University of Puerto
                     organization  of the PR-RMP.  In addition@-to his research role
                                            he capacity of organizaiional.analyst
                     he haslalso served in t
                     and institutional planner.  The primary concern of   the Section
                     during the period September 70-December 70 was the   preparation
                                                       rch" and the "Organizational
                     of the "Outline of Proposed Resea
                     Analysis" in addition to participation in development  .of the
                     Program Master Plan.
                     Beyond the activities mentioned the head of the section partici-
                     pated in the National Confer ence and Workshop on-Evaluation
                     in September 1970.  He also visited other research groups in the
                     U.S. And Puerto Rico for possible collaboration and exchange of
                     data.
                     The research proposed in the "Outline" reflects an innovative
                     approach utilizing the entire community as the   point of departure.
                     From the sociocultural setting a health disease profile including
                     characteristics of supplier and consumers is prepared.  To this
                     profile existing technologies (available or desired combinations
                     of personnel, facilities, programs, etc.) are applied and the
                     resulting quality distribution and continuity of care are
                     analyz6d.. Important elements  in  the  evalu.ation of the system
                     are its capacity to serve the health/disease.profile and the
                     effectiveness with which it consumes its resources in reaching
                     specified goals.  Obvious implications for policy and priorities
                     are included.
                     Some of the basic recommendations in the Proposed Research were:
                     1  -A community oriented, systems based, and interdisciplinary,
                         approach to the  study of the health referral system towarcs
                         national  and  international  comparison.
                     2  -Design of an information system organized around basic files
                         in facilities, p ersonnel; services organization,technology.
                         and sociocultural elements.
                     3  -Necessity for determining relative capacities of sub-systems
                         (Personnel, Facilities, etc.) and the balanced design of these.
                     4  -Need to generate profiles of standard units of analysis (Health
                         Center, District Hospital, etc.) for comparison within the
                         public referral system and to contrast public and private
                         performance.
                     5.- Studies on manpower utilization and system organization were
                         given high priority.
                     6  -Increased sophistication in data analysis and examination
                         of the reliability of data collection procedures.
                     During the coming year emphasis will be placed on studying the
                     organization of the delivery system and designing the basic
                     information system.  Beyond that period the areas of manpower
                     utilization, profiles of standard units will be investigated.





         Puerto Rico RMP                                        RM 00065 5/71



             MAYAQUEZ SUBREGION
                  1.  If the proposal for the Creation of an Inter-Agency Center for
                      information on Early Detection and Treatment of Cancer in the
                      Western Region already approved, is instituted, the subregion
                      will supervise its implementation and aid in its evaluation.
                  2.  If the proposal for the creation of a Continuing  Education
                      Program for General Practitioners in the Western Region  is
                      approved and funded, the subregion will work in the planning,
                      implementation, development and evaluation of the  Program,
                  3.  The subregion will continue promoting the Regional  Medical
                      Program in the Western Region and coordinating
                      activities with all the institutions and agencies in the
                      Region, mostly those dealing with the delivery of health services.






                                                   12-                RM 0006-5 5/71
              .Puerto Rico RMP



                          P@rzrq'O RI'-CO RFGIOkliriT, ;,EDICTIL PPOGi%ri-?i
                          CO'@F STAFF    SAN JUAN r-@7G!ONAL OFFT@CR,

                                 LINE    STAFF OIZ(,-AN-
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            Puerto Rico RMP                -13-                        RM  00065  5/71

                                       CORE STAFF
                                                                               % Hours
            Name                      Job Title or Function                  Time and tffort
      Cristino  Colon,  M.D.          Coordinator                                 1
      Vacant                          Assoc. Coordinator                          100
      Luis Miranda, M.D.              Assist. Coord. Education                    100
      Vacant                          Assist. Coord. Research                     50
      Patrick Crenshaw, M.D.          Assist. Coord. Health Services              100
      Orlando Nieves                  Administrator                               100,
      Carmen Allende De Rivera        Biostatistician                             100
      Vacant                          Hospital Administrar                        100
      Carmen  Lydia Rodriguez         Health Educator                             100
      Betsy Napoleoni                 Tech. Assistant                             100
      Minerva Virella                 Clerk Steno.                                100
      Olga La Luz                     Clerk Steno.                                100
      Betty M. de Diaz                Clerk Steno.                                100
      Vacant                          Clerk Steno,                                100
      Vacant                          Clerk Steno.                                100
      Ada  M. Pabon                   Clerk Typist                                100
      Eunice  Delucca                 Clerk Typist                                100
      Dolor .es del Valle             Clerk Typist                                100
      Joe Nazario                     Messenger                                   100
      Vacant                          Social Scientist                            100
      Maria L. Vigo                   Statistician                                100
        rmen Segui                    Statistical Clerk                           100
        lberto Cardona, M.D.          A.ssociate Coord. (May)                     100
        rmen   L.   Valentin          Clerk Steno. (May)                          100
      R. Norris Blake                 Pub. Relations Director                     100
      Juan E. Perez                   Pub. Rel. Technician                        100
      David Goitia                    Illustrator                                 100
      Luis Vallafa7ne                 Audiovisual                                 100
      Carlos Diaz Mendez              Driver                                      100
                                                                                  100
      .Vacant                         Nursing Coordinator
      Vacant                          Social   Worker                             100
      Herman  Steidel                 Medical Librarian                           100
      Mildred Ramirez                 Statistical Clerk                           100
      Jose N. Correa                  Associate Coordinator (Ponce)               100
      Rosario Flores                  Clerk Steno (Ponce)                         100
      Jose Aveillez                   Assist. Coord. (May.)                       100
      Hector L. Rivera                Coder                                       100
      Zoe R. de                       Assist. Coord.                              100
       Cantellops
      Luz D. Rivera                   Coder                                       100
      Ines M. Olivet                  Research Assistant
      Constantino    Alvarez          Planner                                     100
      Nilda Figueroa                  Research                                    100
      Alba E.  Santiago               Clerk    Steno.                             100
      Brian  Mullan,   Ph.D*          Organization  Specialist                    100





          Puerto Rico RMP                  -14-                         RM 00065 5/71

          THE REGIONAL 'ADVISORY GROUP


                                                                               consider-
            The Regional Advisory Group-reports that the      PR-RMP has had a
                                                                                 studies
                       t: through its operational Projects, Pilot projects;
            able impac                                                                     s
                                              es at the level of health centers; studie
            into the utilization of resourc                           cooperative
            of continuing education; and through     the creation of
            arrangements. TFey indicate that the region has made considerable
            ptogress in the development of a Master Plan for the region, which sets
            the direction and course for the next     four years.
            The region identifies     in  this report the health problems of the
            region in the RMP areas of    concern.  They explain the criteria
            utilized in the establishment of priorities and the problems of
            The size of the Regional Advisory Group has been increased to 25 members
            to include more consumer representation.  It has also developed Regional
            Advisory Group By-Laws which are included in the  April 1971 review cycle
            application. I Nominations for membership to the RAG are made through
            the Program Coordinator and Are subject to approval of the Core staff
            and the RAG.  The tenure of office shall be 2 years with a right of
            succession for one term.  Meetings are held quarterly with an annual
            meeting preceding the anniversary review of the Orogram.  The present
            membership of the RAG includes:
                             Practicing Physicians            2
                             Medical Sciences Campus          1
                             School of Medicine and
                             Medical Center Officials         4
                             Hospital Administrators          I
                             Appropriate,-Medical
                               Societies                      2
                             Voluntary Health Agencies        4
                             Commonwealth Department of
                              Health                          1
                             Municipal Government             1
                             Veterlfts Administration         I
                             Department of Education          1
                             Other Health Professions         I
                             Prominent Civic Leaders          I
                             Health Consumers                 5
                                                              25




          Puerto Rico RMP                   -15-                   RM 00065 5/71


            Executive Committee
            This Committee is composed of the officers  (Chairman, Vice Chairman
            and Secretary) and four members elected by the Regional Advisory Group.
            The Executive Committee is authorized to act for the Regional Advisory
            Group between meetings with actions subject to subsequent approval
            by the Regional Advisory Group proper.

            Task Forces
            The PR-RMP has identified in this application six task forces and has
            indicated that it is in the process of developing guidelines and
            operational procedures for all of these groups.  Indicated below are
            the Task Forces and their total membership:
                                  Planning                10
                                  Stroke                  15
                                  Cancer                  10
                                  Continuing Education    11
                                  Diabetes                17
                                  Heart                   13
            An organizational chart of the  PR-RMP  can  be seen on Figure 2.


              DEVELOFMENTAL COMPONENT
              The region explains that the elements of the Developmental Component
              'have been determined by selection of those items which the program
              development plan logically suggests and which are 4conson;nt with the
              pertinent Sections and explicit terms of the Airlie House document
              of May 1970.
              The alternatives considered in utilization of the developmental
              component ate as follows:
                      1. (Disease Oriented) Kidney and Stroke Studies

                      2. Education-Research Area
                      3. Application of a Health System Model
              The region indicates a preference for alternative number three.,
              A single committee (tentatively the existing Planning Committee) will
              constitute the sole review body for the processing of new proposals.
              To expedite matters the proposal will then proceed directly to the
              Regional Advisory Group.  Administration of the projects would be
              carried out by the Administrator of the Core staff.  The region indicates
              that an adequately functioning working group has already demonstrated
              its capacity to incorporate new projects by a flexible structure
              which responds on the basis of need.





                                                                                                    @M 00065 5/71
               Puerto Rico RMP


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            Puerto Rico RMP             -17-                       RM 00065 5/71

            PROJECT REVIEW PROCESS

            Following are the procedures utilized by the region in,the review of
            proposals:
                 1.   Operational grant application is prepared by the applicant.
                      During its preparation, the members of the applicant organi-
                      zation may seek necessary consultation from the core staff.
            T@iis application is then filed with the Coordinator of the RMP.  ApplicAtions
            are registered by Miss Betsy Napoleoni, using a  "Project Proposals Flow
            and Control Sheetfl.

                 2.   The Coordinator refers the application to his  staff  for
                      analysis and evaluation.
                 3.   The staff will provide follow-up documentation a nd analysis,
                      with regard to the following criteria.
                      a.  That the application proposes to fill  a  demonstrated
                          need in the improvement of patient care, giving
                          emphasis to primary care in relation to heart disease,
                          cancer, stroke, and allied illnesses.
                      b.  That it demonstrates joint and  workable  cooperative
                          arrangements in the organization  and  administration
                          of the existing health services in the Region.
                      c.  That it encourages the improvement and growth  of  the
                          health manpower pool.
                      d.  That funds are to support new programs,  not  existing
                          ones.  Emphasis will be given to exploring new
                          systems of care in relation to heart disease, cancer,
                          and stroke patients and other allied illnesses.
                      e.  That the proposal will provide for a phase out periodic
                          presenting adequate and acceptable sources of support
                          at some future time.
                      f.  That the project is feasible using the  personnel  and
                          facilities in existence or available.
                      g.  That the application provides for meaningful evaluation
                          of proposed activities.
                 4.   A Committee will be formed of two staff members for the review
                      of each proposal.  Suggestions made by this committee will
                      be sent to the RMP Coordinator.

                 5.   The RMP Coordinator and/or representative will  meet  with
                      representatives of applicant organizations to discuss
                      suggestions of various committees.
                 6.   A Core staff member will assist  applicant  organizations
                      in making necessary changes suggested by the  Core  staff
                      Review Committee.  The proposal will then be prepared for
                      review by the Task Force covering the area o  concern
                      presented in the proposal.




          Puerto Rico RMP               -18-                 RM 00065 5/71
                   7. The Task Forces will review each operational Grant Application
                      received from the staff, according to criteria determined
                      by that Committee. Presentation of each proposal  to  the
                      respective Task Force will. be made by representatives from
                      applicant organizations.
                   8. the Task Force may recommend that proposals be forwarded to
                      the Planning Committee or returned to the Applicant Organi-
                      zation under one of the following conditions:  disapproved,
                      or approved subject to modification.  In the latter event,
                      the proposal may be resubmitted following incorporation of
                      the recommended changes.
                   9. If the Task Force rejects a proposal it shall  clearly  state
                      its reasons for doing so. The Coordinator will  then  forward
                      a letter to Applicant Organization stating the reasons for
                      the rejection.
                 10.  Once reviewed and approved by the Task Force, proposals  will
                      be sent to the Planning Committee.  If a proposal is approved
                      by the Planning Committee, it will be sent to Regional Advisory
                      Group. If approved by the Planning Committee  subject  to
                      modification, it will be sent directly to Regional Advisory
                      Group following revision in accordance with the recommended
                      changes.
                 11.  If the Planning Committee rejects a proposal  completely,
                      reasons for the rejection will be clearly stated and a
                      letter will be sent by Coordinator to the Applicant
                      Organization stating the reasons for rejection.
                 12.  Copies of each proposal will be submitted to each  member
                      of the Regional Advisory Group, at least two weeks  prior
                      to a meeting. However, there will be a committee  of  the
                      Regional AdvisDry Group, composed of two persons, who will
                      be,-responsible for the proposals to be discussed.
                 13.  At the time of discussing a proposal at a Regional Advisory
                      Group,meeting, representatives of the Applicant  organization
                      will make the presentation.
                      The Regional Advisory Group Committee which has the  main
                      responsibility for the discussion of the  proposal  shall
                      be permitted to question these representatives.
                 14.  If the application is approved with modifications by RAG,
                      it will be referred by the chairman of the RAG to the RMP
                      Coordinator, who,.together with the Applicant and a
                      representative of the Regional Advisory Group, will reconcile
                      the points objected to, after which the proposal will  be
                      returned to RAG chairman for final approval.





          Puerto Rico RMP                        -19-                  RM  00065   5/71

                  15.  The Puerto Rico Regional Medical Program Coordinator, acting'
                       for the Grantee  Institution,  the  University  of  Puerto  Rico
                       Medical Sciences Campus, will receive all operational grant
                       applications  approved  by  the  Regional  Advisory  Group.  It-
                       will be his responsibility to determin   e that each@application
                       conforms to RMP policies,  and  to  submit  the  application  to
                       the Regional Medical Program Services, Department of Health'
                       Education,, and, Welfare.

             PROGRAM EVALUATION

             The evaluation section of the PR-RMP has established an evaluation
             protocol for both projects and total program.  This protocal is
             identified in pages 71-74  of  the  May  1971,  continuation  application.

             SUPPLEMENTAL PROJECTS
                                                                                 First Year
             Project #14 - Medical Communication Center in the Southern           Request
                           Health District of            ico (P-o@ :              $68,026
             The applicant organization of this proposal is the Southern
             Distric Medical Society of the Puerto Rico Medical Association.
             The purpose of this program is continuing education of practicing
             physicians in this area.  The Center itself will be available for
             physicians on a daily basis so that they can utilize audiovisual
             equipment  and  materials.  Frequent  meetings,  short   courses,seminarsp
                                                                               le
             and  related  activities  are  contemplated.  In  addition,  pottab
             equipment will be rotated-probably at weekly intervals through
             hospitals,health centers and others so that they may avail themselves
             of the learning material at their convenience.
             It is indicated that in the future  the  scope  of  the  program  will  be
             expanded to include paramedical personnel.  The region indicates that
             it is likely they will request for a third-year  support when they
             submit their triennial application

                  second Year:  $68,485


             Project #15 - Creation-of   a Continuation Education Program        First Year
                            for General  Practitioners  in  the  Western  Health  Request
             Region (Mayaquezl: The applicant organizations of this              $14,927
             proposal are the Western Sub-region of PR-RMP, Western       Health
             Region Health Department and the Western Chapter of the Medical
             Association.
             This program proposes  to  create  an  educational  mechanism  to  provide
             continuing medical eduction to the general practitioners in the
             Health Centers and in private practice in the West Region.  The
             program will  concentrate  primarily  on  giving  the  participants
             theoretical information and clinical experience in the treatment
             of  cancer,  cardiovascular  disorders  and  gastrointestinal   disorders.









                                                                      00065 5/71
          Pu6rto.Rico RMP                  -20-


            The course will be of 3 months duration.  It will hAve two'sessions
            per week of@two hours duration each.  The number of M.D.s to be
            enrolled per coursewill be a maximum of 15.  The course will be
            offered three times a year reaching then a total of 45 M.D.s per year.
            It is indicated that a third year of funding may be requested when the
            region submits its trionnal application.

                  Second Year: $16,672







                                                     RMPS/GRB/3/11/71












                                                                                                                          REVISED-3/10/7.


                                                                                               '@YCL
                                               LIZ@@K06T OF @FQUEST         02      -P il@1% iD


                                                                                   NEW
              7: CAI: i 0'14 OF
                                                      R---',.'@-WAL !APPIZ/UNI'UN. !A.-CTIVITIES DTP.ECT
                                                                                                     95,448                     95,448
                                                                                     95 448
         @uavelo-,L-ental                                                                                                                        :z
                                                                                                1 316   405     53
         co@,                              316.405
         'l Fediatric  Cardiovascular,
            Disease                                                                                 150,000     14. 4          164,744
                                           150,000
         02 'Cianatojogy, Cancer                                                                    75  000     1,.,850
            chc:.-btheraoy & Blood Bank       75.000                                                                            86,850
        -7j-f ronic Pulmon. Disease                                                                                            141,284
                                                                                                    125.000     16.284
            Cen!--cr for C,iildren         125.000
                     e@lit-us
                                                                                                     4.595*        6,963        71,558
            -Education Program              64,595*
                                                                                                                                32,500
                                                                                                     25,000        7,500
         .'--5 c--,-ice,- ',Registr           25,000
                 r-                                                                                                            103,645
          7 'tif -t a        Rkl
                                                                                                     90,000     13,645
               s
                                                                                                                               131,540
                                                                                                    112,163     19,377
             Stroke Prevention             112,163    1
                                                                                                                                72,735
         A14 Medical Cori,-m. Center
                                                                                                                                15,877
         fil5 General Practitioners CE











                                                                                     178.401      1,1360564  1   149,176   1,285,,740
                            ,r"),OPN-      @4t8-l63






                                                                       03    77,- 7


                                                                                               7-
                                                                                                                                     0


    Devel@p e@, t
                                                                                                                                     0
                                                                                                                               48


    co@
                                                                                                             316,405     369,559

                                                                                                             150,000     164,744

                                                                                                              75,000       86,850

                                                                                                             125,000     141,234


    .4
                                                                                                              64,595      71,518*

                                                                                                              25,000       32,500


    -@7
                                                                                                              90,000     103,645


    ir
    rio"
                                                                                                             112,163     131,540.


    @14
                                                               68,485       68,485       8,824    77,309     136,511     150,044*

    #i5
                                                               16,672       16,672         950    17,622      31,599     .33,499*









                                                               85,157      85,157       9,774     94,931   1,221.721    1,380,67'1'
                       *Budget Estimates  for 3rd year t
                                                         o be  i
                                                               ncluded in Triennium  Review ApPlication.




                                                                                                                           RM 00065 5/71
                                                                  -23-
                                                                               PUERTO RICO
                                                                                                         C,ircriiit opLritioiiil Year:  6/70-5/71
                      I.i:o,.,(@d for Ciii-,7(tnt Yc-.-ir     -------------- $ 1 246,250            t    Fir@t Sche,2uled Ai cipp.lication Feb.  71
                   Olleritill? ]C'Jel  In CLirrent Year                       9                          April 1971 Committee                     .. .
                     includes funds carried for-.iard.)            -------$    958,163                   Region's   optional   plans:    None
                   Recomincnded Coinmitr-.ent  for  next  year       ---  $    958,163


          CO:4PONE'4TS BY DISEASE C."'ECORY                     F-IOPOSED.CO'-POliENTS                                     CO",PC'@'E,;TS BY TYPE OF ACTIVIT
     EART                                                                                                                       AND    EDUCATION
          C-)-i'Oing                                                                                                       n-going            I   .
            i7 Projects   2                                   Project'#14 - Medical                                          #  Projects   3
            'rota I.ss  240,0.00                                                                                             Total ss 225,919
            7. $5  25%                                        Communication Center                                           % $S 24
          ,'Ai-.Pro,jcd/u@ifunded O                                  $68,026                                               Approved/iinfunded         1
                                 0                                                                                         Dis6pproved        1    -
          Di.,,ir)provcd


      :A'@CER
          Cn-ioing
              Projects      2
            --.t     s  '100,001
                -i s                                                                                                DF,'-10'4STFATION OF PATIENT CARE
              $S  10                                                                                                       On-going
          Apl@rovc(4/ii:iftinded                                                                                                Projects      4
          r)t,lppro-"Cd  0                                                                                                   Tota    I    $S    412,163
                                                                                                                             '/  ss  43
                                                              Project  #15.-  C.E.
                                                                                                                           !,V,@)rovt-,d /iiii Etinr3ed 4
          On-going                                            Program  for General                                         Disapliroved       0
               Pr,)Iects                                      Practitioners
            'rtIZ.3ijssII2,163
            7@ $s     12                                                  $14,927
                                  1
                            0                                                                                        RESE,i.-@CH & DE%'ELOPI@TENT
                                                                                                                           On-going
       (IDNEY                                                                                                                   Projects
                                                                                                                             Total $S                 0
               Projects                                                                                                      % $S
            ,r,) ti 1 $S         0                                                                                         AI)projed/lnftinded
               $S
                                                                                                                           Disappro-ved





                     DISEASES
                Projects   2                                                                                   AD,-11141@;fRA'rlON    &     P@INING
             Total      @8       185,919                                                                                On-Roilig
             % Ss                                                                                                       !@ projects           (core)
            ""-,PL-,)Vc,.d/unfund@d    0                                                                                Totil      Ss       320,081
                                                                                                                           $s 33
                                                                                                                      I L,, p p r ov,-, d0

             ,@l   rroj,@cts' 0
             Total    $S    0
             % $S      0
            Approved/Linfticided       0
                     oved



            on - j-,o I I'l 9
              if     Projects  I  (Core)
              T,)t,il     ss     320,081





                                         -24-

                         DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE
                                        PUBLIC HEALTH SERVICE
                          HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION


            Marchlt, 1971
    Rtp@ to
    Alin of.-
     Subjtcl: Staff Review of Non-Competing Continuation  Application from the  Puerto  Rico
            Regional Medical Program for May 1971 Review C' te  5 G03 R@l 00065
                                                             yc
       To:
            Acting Director
            Regional 14edical Programs Service

            THROIJGH4. Chairman of the Month
                       Chief, Grants Review B

                       Chief, Grants Manag en,.ent Branch
                       Acting Chief, Regional Development Bra'ncl


            Rec6mmdnd-ation:  Staff recommend continued support of Core and seven
            onpoin7 projects at the committed level  of  $958,163  for  the  regions  second
            operational year. Based on the recent!Reduction, however, of the  Cor.-,,-@iit-
            ment by the RMPS of $81,443 the repion's commitment  for  fiscal  year  '1197111
            Is $876,720.
            Core                                     $316,405
            Operational. Projects (7)                 641,758
            Staff Recomirendation                     958,163
            Deduction  by RMPS                         81,443

            Basis for  award                          876,720
            Staff review of the continuation application concentrated on overall program
            issues.  ?4ajor issues discussed by staff were:
            Regional Advisory Group - Four  new  members  have  becn-added  to-the  Regional
            Advisory Group, all  representative  ot  the  health  consumer.  They  are:  an
            industrialist from Ponce, an  insurance  executive,  a  banking  executive  and
            an attorney. Staff  believes  this  increase  in  consumer  representation  will
            strengthen the RAG, however, consumers to represent the lover economic
            population and the li'odel Cities Programs are not represented.  The 17orthern
            and Southern areas of the region are well represented on the RAG, but there
            is no representation from   the Western and Eastern areas of the region.
            The RAG report is general   and  nonspecific.  It  gives  the  impression  that







                                           - 25-


           Page 2 - Dr. Margulies


           the r%AG has not a8suELed the leadership role for the PR/PIT.  With the
           caliber of persons on the RAG, this group, it they assumed strong  leader-
           ship of the program, could have a positive rather than a passive in-
           fluence in the health care system of Puerto Rico.

           Staff believes that if the PR/RIT is to effectively serve as a catalyst  in
           bringing the two major providers of health services in Puerto Rico -  Private
           and government medicine - to jointly confront the major health problems  of
           the region, it will have to do so throuoh the leadership and active  parti-
           cipation of the RAG.  Staff suggest that methods of operation, responsibilities
           assumed, and utilization of manpower  of this group should be a topic of-dis-
           cussion in future site visits.


           CORE

           The Core staff has been increased from 29 to 44 positions. This  increase  in
           staff is primarily for the acquisition of personnel for the subregions  of
           Ponce and Mayaquez.  It also includes personnel from the recently organized
           Planning, Research and Evaluation Section of the central core office    No
                  C)
           additional funds are requested for the new positions.    ey are to b;  funded
           from within the level of funding for Core by utilizing available funds from
           vacant positions.

           The utilization of these core funds to support these new positions may
           presently restrict the region from filling the positions of social  worker,
           hospital administrator and registered nurse now being recruited.  It  will
           hO-v7ever,,allow the region.:to establish a subregion in Ponce and 14ayaquez
           and to strengthen its planning and evaluation for central core staft  which
           ate priority items.

           TASK FORCES

           The membership on the task forces primarily consists of physicians, with
           little if any representation of allied health personnel.  Staff believes
           that allied health personnel can contribute and should have an  opportunity
           to participate in the task forces.
           It appears.to staff that there is little organized interrelationship  between
           the task forces, nor an established operating procedure which would stimulate
           an integrated program effort between task forces, RAG, Planning  Committee
           and Core.  It is suggested that core staff input be built into the meetings
           of these groups to keep them abreast of total program activities and to
           encourage further input by these groups into the PR/RMP4
           The general impression of staff is that the task forces have been project -
           oriented and have not assumed the responsibility for developing a  Regiona






                                            26-
            Page 3 - Dr. Margulies
            plan of action for each of the categorical areas they represent.  This lack
                                is apparent in the pro-ects which have been submitted
            of regional planning                       i
                               of how each activity interrelates-with others in the...
            There is no mention
                                                               on of how ea h activity-
            same categorical area.  There is,also little menti.            c
            fits into a regional  plan.  Staff.suggests.that in   future site,visits
            these concerns of staff should be included as  a to'ic  for discussion.
                                                               p


            OPERATIONAL PROJECTS
            The seven operational projects, have been funded for less,than a one year
            period.  Taking this into consideration, staff concurred that they have made
            satisfactory progress. When the region  is  site visited,.*Project #10
            Community Family                     n Stroke and Its In  vacitatin
            Complications                        o see what progress has been i  e.  This
            is in line with previous Council recommendations.  The region reported some
            difficulty locating space for this project Y@10 at the Guayn.abo Health Center
            and also with the recruitment of staff.  They have however, indicated that
            these problems are being resolved.

            GENERAL
            .Staff believes that cooperative relationships have been established and  the
            regionalization process is developing.
            The Region has defined as major problems within the government health system
            poor organization, utilization and administration of health resources.  it
            would be interesting in a future site visit to see what the PR/IU4P is doing
            to assist government medicine in resolving these problems.
            The following staff members at-tended the meeting    March 5. 1971
            Ismael B. @foralesi Grants-Review Branch, Chairman
            Loretta W. Brovni, Otfice of Program Planning and Evaluation
            Lawrence H. Pullen, Grants Management Branch
            Frank S. Nash, Regional Development Branch
            Elsa J. Nelson, Continuing Education  and  Training  Branch
            Jessie F. Salazar, Grants Review Branch
            Mike Posta,,Regional Development Branch
            Cleveland R. Chambliss, Office  ot  Organizational  Liaison


                   B. Morales
            Public Health Advisor
            Grants Review Branch





            *Implicit in the original recommendation of approval, was the interest





                                              27-
         Page 4 - Dr. Margulies
         in seeing this project develop into a pilot training center and stroke
         resource for all of Puerto Rico.  The site visit team felt, however,
         that this would not-take place unless follow-up consultation was provided
         once the project began.  Since it is too soon for a program site visit,
         it-might be well to have a special consultant visit the project some
         time soon.





         Sa ah J. Si
         Chief, Gtants Review Branch




                                                                 @@A Privileged Coriniunication)


                                  SUMMARY OF REVIEW AND CONCLUSION OF
                                      APRIL 1971. REVIEW COMMITTEE


                                  PUERTO RICO REGIONAL MEDICAL PROGRAM
                                              @l 00065 5/71


                           FOR CONCO)IDERATIOI\L BY MAY 1971 ADVISORY COUNCIL


             RECOMMENDATIONI*@   Committee recommends a funding     level  of   $973,090
                                 direct cost for support of Core, seven operational
             projects  and  two  new  projects.  The  request  for  a   developmental
                                                           4
             component award was disapproved    .  Taking  -nto   consideration   the
             recent administrative action  by  R'i,4PS  which  reduced  the  Region's
             fiscal  year  "1971"  commitment  by  $114,980,  the  operating   level
             of funding will-be $858,110.
                                                         DIRECT COST ONLY

               Year                           Request                  Recommendation
                 02                          $1,136,564                $973,090,@
                 03                              85,157                @ 16,672 (P@oj. #15)
                 Total                       $1,221,721                $bl--9-9,762
             *InclucTes funds committed   for core and'seven    on-going projects; actual
             funds to be awarded will be reduced by $114,980 thru administrative action.


                        Committee believes    that  although  the   seven   on-going
                         projects have been   operational  for  less  than  one   year
             most of them  have  managed  to  give  the  Puerto  Rico  RMP  visibility
             and  outreach.  Concerns  were  expressed  over  the   cancer   registry
             project which has  had  a  chronic  problem  with  folloi,7-up  activities.
             The region may  want  to  evaluate  this  activity  in  rclation  to  other
             priority  activities  which  they  may  be  able  to  fund.   Committee
             suggests,that as recommended by the last site visit team,,i
             special consultant visit should be scheduled for Project #10
             Community Familli Prevention Program on Stroke and Its
             Complications.

             Committee was  encouraged by the increased representation of consumers
             on  the  RAG,  however,  consumers  to  represent  the  lower  economic
             population  And  the  Model  Citi.es  Programs  are  not  included.  They
             also noted  that  although  the  Nortnern  and  Southern  areas  of  the
             Region are well  represented  bb  the  RAG  there  is  no  representation
             from  the  Western  and  Eastern  areas.  In  addition.  the   membership
             on the  RAG  primarily  consists  of  top  echelon  personnel  with  no
             representation from the allied health professions.  Committee
             believes tnat allied health p@r--:onnel need to be represented on the
             RAG and other committees of the PRRIAP.      Overall -.t  does  not  appear
             that the RAG has assumed the leadership role for the PR@IP.





           PUERTO RICO RMP
                                                  -2-             RM 00065  5/71

           There seems to be a tendency in the PRPIIP to become institutionalized
           away from the University, Department of Health and  other  major
           health institutions. Committee believes the PRRMP  can  be  more
           effective if they assume the role of catalyst and  devote  their efforts
           in stimulating cooperative arrangements in health  planning  and
           program development between the major providers of  health  services
           in the region.

           Committee expressed some concerns about Core not having adequate
           representation from the nursing and social services professions
           which could enhance their outreach into the community.


           Committee believes that the new projects submitted in this application
           do not address the real needs of the region.  They focus on continuing
           education for physicians in the health centers and,,overlook the
           private practitioners in the community.  Committee believes that the
           primary goals of these projects should be to stimulate a cooperative
           relationship between private and government medicine so that they can
           cooperatively meet the health needs of their community.  This is
           especially true now that PL 56 has been passed by the  legislature,
           which permits payment of services of private patients  in  government
           hospitals and for indigent patients in private hospitals.  In addition,
           Committee believes that there are good opportunities now  in  Ponce
           (Southern Region) and in Mayaquez (Western Region) for the PR'RMP  to
           have an impact because both areas are deve'lopin,- medical centers.  By
           getting in on the ground floor, the PRRMP may be able  to  influence
           the development of cooperative arrangements and  a  regionalization
           'Process that would involve both government'and private medicine  in
           the areas. Particular emphasis was  placed  on  Ponce  by  Committee
           because it has progressed much faster than Mayaquoz.

           Committee did not recommend additional funds'for Project  #14,  but
           did encourage its development and support from local resources.
           They recommend that this activity be coordinated with  the  already
           existing continuing    education program established in Ponce by
           Dr. Hector Rodriquez in coronary care.

           For Project #15, Committee recommended-an 'award of $14,927 with  the
           recommendation that the program be expan ed to include  the  private
           sector of medicine and allied health personnel.  This project is
           viewed as the creation of a continuating education program  for  the
           May4quez Medical Center area.





                                                 RMPS/.GRB/4/26/71





                                  REGIONAL MEDICAL PROGRAMS SERVICE
                    SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION
                                    (A Privileged Communication)


               SOUTH CAROLINA REGIONAL MEDICAL PROGRAM                  RM  35-04   5/71
               Medical University of South Carolina                     April 1971 Review Committee
               80 Barre Street
               Charleston, South Carolina     29401



               Program Coordinator:  Vince Moseley, M.D.

               This region is currently funded  at  $1,292,791  (direct  costs)  for  its
               third.operational year (which is  an  11-month  period)  ending  June  30,
               1971.  Core is supported at $456,498 (d.c.) and 16 projects at $836,293
               (d.c.).  The Region has submitted a triennium application that proposes:

                             I  - A Developmental Component
                            II  - The continuation of Core and three ongoing activities
                                  (#5A, #29, #31).
                           III  - The activation of I  Council  approved  but  unfunded
                                  activity (#22)
                            IV  - The renewal of 1 activity (#13R)
                             V  - The implementation of  20  new  activities  (#39-#58)
                            VI  - The termination of 12 activities


               The region requests $2,991,048 (d.c.) for its fourth year of operation,
               $2,727,436 (d.c.) for  the  fifth  year  and  $2,993,955  (d.c.)  for  its
               sixth year.  A breakout chart identifying the components for each
               of the three years is presented on pages 3-5 of this summary.

               Four of the proposed  new  activities  have  previous  review  histories.
               These Are projects #47,54,56 and  58.  This  point  will  be  elaborated
               on later in the body of this summary.

               A site visit is planned for this Region.  Staff has conducted a
               preliminary review of the application, which as a result of new      polic@es
               is quite superficial and  leaves  many  questions  unanswered,  and  has
               identified the following  as  issues  which  need  further  clarification
               at the time of the site visit.  These are covered in greater
               detail  in the attachment to this summary.

                    1. The functioning of the large 70-member RAG.
                    2. The effect of the  RAG's  composition,  with  the  preponderance
                       of the Medical Society and  hospital  interests,  on  the  program
                       priorities and policies.
                    3. The effect of  the  various  committees'  composition  on,program
                       priorities and policies.
                    4. The s ecific functions of Core Staff members and their relationships
                            p
                       to the community, Local Advisory Committees, RAG and each other
                    5. Thepprogram objectivesthe bases  on  which  they  were  establishe
                       'the time frame for achievement and  the  method  of  evaluation.
                    6. Clarification of the review process.
                    7. The evaluation processes, both project and program.







           South   Carolina
           Regional Medical Program              -2-                   RM 35-04  5/71








                                     FUNDING HISTORY


                                     Planning Stage

               Grant   Year           Period              Funded (D.C.)
                    01           1/l/67-12/31/67           $100,673
                    02           1/l/68-12/31/68           $316,675
                    03           I/l/69-7/31/70            $420,000


                                    Operational Program

          Grant   Year       Period            Funded (D.C.)          Future Commitment (D.C.)
             01           B/l/68-7,/31/69       $826,435 1/
             02           8/l/69-7/31/70       $1,177,626 2/                 -----
             03           8/l/70-6/jO/71       $1,292,791 3/                 -----
             04           7/l/71-6/30/72                                 $563,477 4/
                                                                         $202,255 (5  mos.
             05           7/l/72-6/30/73                                                   )5/




          *The indirect cost rate for.the Region for the current year is approxi-
           24.1%  and   represen ts $312,016.

          1/ (Projects  only,  Core  still  under  planning)
          2./ (Core only partially supported $202,256 (d.c.) by this award)
          3/ (This represents total program support, both Core & 16 projects
               for  11   months)
          4/  Core  and  Project #29
          5/ Core only






                                                                                                                    SOUTH      CAROLINA
                                                                                                                    RM    00035    5/71
                                                                              04
                                                                                                                         (Triennium)


        @ENTIFICATION OF                 CONTINUING                     P@viougLY          NEW
        MONENT                           ACTIVITIES.    @EWA-T          APPRIUNFUND,         ACTIVITIES    DIRECT        INDIRECT          TOTAL
        ,RE                              $615,490                                                         $        615,490 $207,686    $     823.176
        A CCU Nurse Training                  56,877                                                            56,877      16,169           73,046
                                                                  08                                            45     808   8     2
        3R Mid. G.I.                                                                                                          31 3 --      ___54.140
        2 -  MUS  Heart  Clinic                                            $67,816--                            6    816-     161023         83,839
        9-Pediatric Heart                  -7?,  065                                                            78,065  __@231127_        ---101.1192
        @l-Demonstration Project-'
                                                                                                                62    -700 L7                      63
          Con               cation            62,700                                                                          .@lh-I -"  - @- - 7-9,.$
        58-Comprehensive       CCU                                                           106,900          106,900      36,750          143,650
        39-Statewide Heart                                                                    59,71.8           59,    718 -12,194-,-..      71,,912
        'O              e                                                                     62    154         62,154     12,544            74.698
        - Stroke Nurs
        @l-Midland Stroke                                                                    148,928          1-48,928     30,712          179,640
        @2-Heart Implementation                                                               99.626            99.626     172816          117,442
                                                                                                     64  1      4
        @3-Hypertension                                                                       40,5              0,564      10,633            51,197
        @4-Statewide      Cancer
          Clinic                                                                              49,908            49.908      9,440            59,348
        @5-Nuclear      Medicine                                                              68,785            68,785                       68.785
        @6-Hematologic         Mali&nancl4s                                                   812913            81.913_i   19,600          101,513
        @7-Oral Cancer                                                                        30,271            30,271      3,308            33,579
                                                                                                              24
        @8-GEecolo@ic/ Radiother,                                                            240,165            0,165      55,272          295,437
        @9-Lab Training                                                                       32,470            32.470      4,401            36,871
        io-Mid. Education                                                                    129,118          129.118      23,770          152,888
        11-Continuing Education
          Health Person                                                                                                    30,723          2831462
                            nel                                                              252.739          252,739
        @2-Health Manpower                                                                    68,115            68,115      4,303            72,418
        13-Information Network                                                                71,587            71,587     14,112     i      85,699
        14-Planned       Discharge                                                            50.800            50.800                       50.800
        ,5-Hemodislysis                                                                       65.194            65,194     21,511            86,705
        16-Comprehensive Respitatiory
          Disease      Training Prog.,                                                       179.487          179,487      27.685          207,172
        7-Continuing Medical
          Education                                                                          100,850          1001850      24,107          1,24,957--

        :VELOPMENTAL    COMPONENT                                                            125.000          125,000                      125,000
                                         $813,132          $45,808         $67,816           $2,064,292  $2,991,n4s      :'647,381    $3,638,429
                           TOrrAL                      I               I               I                 I               ?





                                                                                                                 "I uuu.5D    i
                                                                     -SI,
                                                                            05       -P      I'@ i ci 13         (Triennium)


                    02
                                      c O'@ I"
                                                                                         El'
           T                         'AC@LIVITTES
                                                                    ;APPR/U                 I'PIES    DI.R---CT       -INDIRECT       TO-@AL
                                                                             NFUN.  @ACT,RV                        @T

    Cl)E
                                       $650.035
                                                                                                          650,035      $218,069              04
    #5A
                                         58,845
                                                                                                          58,845       16,978
                                                                                                                                             23
    #22
                                                                      $52,867
    029                                                                                                   5@2  867     16.824         69,691
    F3
    058
                                                                                                 45       115,645      38,588         154,233
    @39                                                                                          0
                                                                                         68,50            68,500            083       82.583
    @40                                                                                                                i4s
                                                                                         61                                 139       74,401
    P41                                                                                                       -
                                                                                         148,928          148,928      30.7           179,640
    @42                                                                                                                      12
    @43                                                                             i    117,208          117,208      18,761         135@  69
                                                                                         41,793           41,793       11,165         52,958
    @44
                                                                                         50,032
                                                                                                          50,032       10,327         60,359
                                                                                         60    649        60,649                      60,649
    @46
                                                                                                 8
                                                                                         84,22            84,228       24,696         108
                                                                                                 -                                         924
                                                                                    i    33,905           33,905       3,638          37,543
    E48
                                                                                         201,633          201,633      63,916         265,549
                                                                                          5.     9        2 5-.-O 9@,  4,535          29  6  9
    t5O
                                                                                         117,706          117,706      24,796         142:502
                                                                                         228
    @52                                                                                                   Z8.301       41,079         2699  80
                                                                                         70,695           70,695       -4,518         75,213
                                                                                         105,417          105,417      22,168
                                                                                                                                      127,585
    @54
                                                                                         41,83(                                       41,830
    !55                                                                                  69,914           69,914       23,662         93,576
    -56
                                                                                         93,156           93   156
    57
                                                                                         79,793           79,793       22,940,        102,733
    EVELOPMENTAL COMPONENT
                                                                                         150,000          150.000                     150.00




                      TO'FAL         $708,880                         $52,867          :$1,965,689     @$2,727,436      $653,663     @$3,381,099











                                                                                      B,@EA'Kolj'@r  Or              U'@7, S T           PR-RIOD
                                                                                                                                                                                             RM  00035         5/71

                                                                                                                                                                                             Ai-T      Y-7-AR@--i
                                                                                                                                                                                                                         AL' -f--  AP  S
                                                                                           IC,_'
                                                                                                  LY
                                                                                                                                  1      T)Trr                         T
                                                                                                                      A.CTIVIT.@1:2
           ot-  r,-"                        7 1
                                                                                                                                  i      679,538      IS228,973             908,511          $1,945,063                    $2,599,7c)l

                                                                                                                                                                                                    45,808
                                                                                                                                                                                                                           54,140
                                                                                                                                                                                                                           22-
                                                                                                                                                                                                    74      9_Q4             @06.-
                                                                                                                                                                                                    78,065                 101,192
                                                                                                                                                                                                    6 2                        861-
                                                                                                                                                                                                    325,646                441,5nl
                                                                                                                     103.1(1                                  40,517        143,618
               5                                                                                                                  ;      103,101      .                                                                              'I
                                                                                                                     7 3, 5  (  0        73         5no       15@15,9
                                                                                                                                                                                                                           227,  1  nO
                                                                                                                     64,213              64  .   2   43       1 3. 75  8      78,      O')l         187@@
                                                                                                                                                                                                    441      114           538_920
                                                                                                                     148,    Q'-S        148,928              3 0, 71  2    179       6@41)
                                                                                                                     118     l@,9        118.1391             20,163        138.302                 334.973                391,  71  3
               t, 2
                                                                                                                     43,0@2              43.082       1       11.723          54       805?         125.439                158.960
               443
                                                                                                                                -9i      51,809               10,709          62.518                151,749                182,225
                                                                                                                                @6       130,106      i       ---           130,106                 259,540                259     540
                                                                                                                     130,1@-
                                                                                                                                                                                                    261,711                315,613
                                                                                                                     95,5..O             95,570i              29.606        125,176
                                                                                                                     35,7(--6            35,746i,             4,002           39,748                99,922                 110,870
               "47
                                                                                                                                                                                       @-84         660,634                860
                                                                                                                    -2  -8      -6 -2 2  -@,  -8  -i  -6 -7
                                                                                                                                                                                                                               8 3 3@
                                                                                                                                         25  -     749i       4,676           30,425                83,313                 96,925
                                                                                                                                                              -5 -                        --
               149
               f.                                                                                                                                                                       192         713,023                834,034
                                                                                                                                                                                          @@f 7i,--5f o-
         L                                                                                                                                                                    r9@@
         I                                                                                                                               111,177              23,276        134,453@                Z66,    IZ51           347,7@37
               5  3
                                                                                                                                                                              45.613                138.243                138,243
               @54                                                                                                   45.613              45.613:
                                                                                                                                                                                                    211.989       i        28'1    190
                                                                                                                     7  6@8  @'Ll                                   @128      02,I),)9                                              --
               i@55
               6@-                                                                                                   196.3@')l           1-96,     361;       37.383        233        7LA:         469,004                563,141
               '157                                                                                                      1   8193 1  -                        3.            106         712         263,526                3'11@,407
                                                                                                                                                                            200,000                 475,000                475,000
               DE%IELOP@-@iTAL        i                                                                              200,000             200,000:




                                                                                                                                                                                                             439  @$1 0, 7- 3@,
                                                                                                                     ;,$2,26n,106 !2,993,9551'                  $690,038 3,683,()93@:$S,712
                                      i  $67q,538                                     $54,311
                                                                                                                                                                                                                  GRB/2/8/71




           South  Carolina               - 6                              RM 35-04 5/71
           Regional Medical Program


           GEOGRAPHY, DEMOGRAPHY. AND CHARACTERISTICS

           The boundries of the Region coincide with those of the State of South
           Carolina.

           Despite urbanization  and  suburbanization,the  Region  remains  chiefly
           rural or small town, and 57% of  its  population  is  rural.  Of  the
           total population of 2,700,000 approximately, there are only 15 towns
           in excess of 10,00 population.  The five major cities are:

             Charleston - 79,500       Columbia  -   100,000
             Greenville - 67,000       Anderson   -   41,000
            Spartanburg - 47,000

           Spartanburg and Rock Hill are designated  as  Model  Cities  by  HUD.

           The University of South Carolin4  in  Charleston  is  the  only  medical
           school in the State.  There  are  29  institutions  of.higher  learning,
           16 technicaleducation centers, and 100 certification programs in
           the health field in 47 hospitals.

           The median income in 1968 was $7,966, but 27.2% of households had
           income less than $3,000 per year.

           In 1968 there were 2,137 licensed   physicians in the  State,  of  which
           173.4 per 100,000 population were   in urban areas  of  practice  and
           only 34.8 in rural areas.

           There are about 7,698 RNs  in the  State of whom 73% are actively
           employed.

           There  are 2,912 LPNS, 83% of whom are employed.

           There  are 102 hospitals with a total.of 2,225 beds.

           There  are approximately 55 black physicians  in  the  State  and  the
           Palmetto Medical Association is the recognized black medical Association.

           There  are 11-StaEe-A-la Canc'er'Clinics and 9 State-Aid Heart-Clinics,

           The  State is divided into 10 comprehensive planning districts.




           Causes of Death - Rate per 1,000

                         All
                        Causes     Heart    Stroke   Cancer  Accidents
           U.S.  1968    8.20       3.73     1.05       1.11     .68
           S.C.  1968    8.77       3.14     1.18       1.15     .74





            South Carolina
            Regional Medical Program             -7-               RM   35-o4  5/71



                                     HISTORY AND DEVELOPMENT

            The Regionts initial planning year began on January 1, 1967 and
            was supported by two awards totaling $100,673 (d.c.).




            An award of $316,675 (d.c.)was made for the second year  of  planning
            1/l/68-12/31/68.

            In May 1968 Dr. Joseph C. Chambers replaced Dr. Charles  P.  Summerall
            as Program Coordinator.

            A pre-operational site visit was conducted in June 1968 following
            submission of 20 operational projects.  The team consisted of Edwin L.
            Crosby, M.D. (Chairman), Henry M. Lemon@ M.D.,  Robert  L.Schmitz,  M.D.,
            Donal R. Sparkman, M.D. and RMPS Staf:4 Frank R. Mark, M.D., Sam 0. Gilmer,
            and Robert E. Jones. It was the consensus of the  visitors  that  the
            Region was prepared to inaugurate an operational program.  Representation
            on the RAG appeared geographically balanced and to involve sectors of
            private and public health interests as well As the  consumer  public.
            Representatives of the State Board of Health, who were  to  administer
            Comprehensive Health Planning, and RMP representatives  gave  aIssurances
            that both programs were compatible and will work  closely  together.
            Administrative arrangements for program planning and  development  seemed
            to be developing at a satisfactory rate particularly in view of the limited
            number of staff available.  While the team was impressed with the caliber
            of the present core staff it was obvious that attention should  be  given
            to the expansion of staff capabilities.   The development of  cooperative
            arrangements seemed to have provided a sound base from  which  to
            build a program in the future and it appeared that interest and involve-
            ment in the SCRMP had developed to where the broader  community  was
            looking for tangible results.  In view of the absence of
            a continuing education program in the Medical College the  Region  was
            considering the development of this resource at the Assistant or Associate
            Program Coordinator level. The visitors recommended  approval  for  16
            of the 20 projects reviewed.  Committee and Council saw fit to approver
            17 of the 20 projects and an award of $826,435 (d.c.) was  made  for
            their stipport'for@the period 8/l/68-7/31/69.  Shortly thereafter two-
            tore awards were mad&, totaling:$420,000 (d.c.) to continue  planning
            year 1/l/69-12/31/69.

            On January lil969 Dr. Vinde Moseley replaced Dr. Joseph Chambers
            as Program Coordinator.

            Following the submission of a supplemental application  consisting  of
            11 new projects a second site visit was made in April 1969.  The team
            consisted of Henry M. Lemon, M.D., Lamar E. Crevasse,  M.D.,  and
            Sam 0, Gilmer, Jr., PIIPS Staff. The visitors noted that  SCRNP  was
            still in a transition state between the planning stage  and  true
            operational status.  The coronary care projects were progressing
            unevenly and other operational activities have been  organized  slowly
            because of the understaffed and underfinahcial condition  of  the






            South Carolina
            Regional Medical Program           -8-                    RM  35-04  5/71

            South Carolina Medical University and the dispersed nature of the
            principal hospital facilities.  It was believed there was a need
            to develop the Medical College's programs so that better leadership
            could be generated for the community hospitals of the state.  The
            new Coordinator Vince Moseley, M.D., was already contributing much
            to the continued progress of SCRMP.  The visitors noted that while
            consumer and community representation on the RAG had increased, physician
            interest strength had also been enhanced with an extremely large
            number of representatives from the medical society.  Also, there
            seemed to be a great  influence of the hospital administrators, and
            under representation from consumer groups representing the large
            minority segment of the population. There was only  one  representative
            of the nursing community.  There had been a disinclination to
            develop anylocal priorities as to the importance of the various programs
            for which @ support had been requested; and there had  been  no  effort
            to route those projects which might be more appropriate for comprehensive
            health funding to the proper agencies.  It was felt the RAG would
            have to set their own priorities and develop a better regio'nalization
            concept of their activities than they have developed at the present
            time. It was felt a more centralized educational and  advisory  program
            needed to be developed at the Medical College.  While Committee and
            Council concurred with the visitors'recommendation to approve six
            of the eleven projects 31 no immediate award was made.
            In July 1969 Staff reviewed the continuation application for the
            02 operation which requested continued support for 15 of 17  originally
            funded projects.  The projects at tha t time appeared to be moving  along
            very much as anticipated although the evaluation was not well  outlined
            nor were the objectives very clear.  As a result of the review and
            a subsequent request for use of unexpended funds to support approved
            but unfunded projects the Region was awarded $1,066,091 (d.c.).  Of
            this,$202,256 (d.c.) was ayarded Core for the seven month period
            1/l/70-7/31/70 and $843,835 (d.c.) was awarded for 15 ongoing  projects
            .C       riod 8/l/69-7/31/70 and three approved but  unfunded  projects
            1-or the pe
            for the period 11/l/69-7/31/70.  This award served to incorporate
            planning and operational funds into one grant period.
            In January 1970 a Management Assessment visit was conducted to the Region.
            The visitors consisted of:
                     Albert Heustis - Coordinator, Michigan RMP
                     Alfred Popoli  - Tri-State RMP
                     Richard Sasuly - California RMP
                     Richard Metzinger - Maryland KIP
                     Thomas Simonds - Regional Medical Program Service
            The visitors were favorably impressed with the administrative management
            of this Region.  All details contributing to a well-managed program
            were being studiously observed and policies were well developed.  There
            appeared to be an excellent flow of communication between the Coordinator
            and staff as well as between staff members themselves,and the interests
            of both the grantee and SCIOT appeared well protected. The plan to  sub-
                                          P planning districts with subregional
            divide the state into four SCRM





      South Carolina                          -9-
      Regional Medical Program                                              RM 35-04  5/71

                 offices in each was considered a sound and positive step  forward.
                 The RAG which had increased both in size and  representation
                 was considered a properly represented body.   Although project
                 ideas had originated from appropriate sources and had been reviewed
                 in RAG committees it was noted that in many instances the reviewers
                 were also the applicants.  The visitors recognized a need in
                 the SCRNP to significantly increase its data gathering effort
                 and to strengthen its evaluation process., There was a  need
                 to expand evaluation to which determination of whether fun s
                 were spent on the manner originally agreed upon,  assessment
                 of immediate training effects, and effects on professional behavior.


                 In July, 1970, Staff reviewed the Region's Continuation Application
                 for its 03 operational year 8/i/71-7/31/71.  While the overall
                 program appeared to be making significant progress, some concern
                 was expressed that the Region was not giving adequate attention
                 to the supervision and evaluation of projects, nor did it appear
                 that Core staff or the RAG were using evaluation information in
                 their decision-making process. For its 03  operational  year
                 (8/l/70-6/30/70) the Region was awarded $1,292,791 (d.c.) of which
                 $456,489 is for Core support And $836,293 supports 16 projects.





                                      PRESENT APPLICATION


                 Core:  Request is being made for a total Cote Staff of 44      Requested
                       positions; 28 professional positions and 16 secretar-    Fourth Year
                 ial and clerical positions.  Of the professional positions     $615,490
                 two are paid as consultants.

                 Only four of the professional positions and three of the
                 secretarial positions are currently vacant.

                 Seven of the professional positions are filled by M.Ds..





                 Fifth Year:  $650,035                     Sixth Year:  $679,538


                 Activity of Core:  While the major functions of the Heart Section,
                                   Cancer Section, and Continuing Education Section
                 of Core have been basically to set related objectives and  develop
                 project applications to meet them, they have also been engaged
                 in other staff activities including; planning and implementing
                 related educational conferences, and workshops addressing  various
                 professional groups, offering technical consultation to hospitals,
                 assessing ongoing projects, and working with other  health-related
                 agencies in developing them as future resources.





            @oucii uaro.Lina
            Regional Medical Program                              RM 35-04   5/71




            The activities of the Medical Districts Section has  been  limited
            to its basic function which is to establish ten  Medical  District
            Committees as liaison groups with heatlh Planning agencies, general
            planning and develop councils, professional  and institutional
            groups in the various districts and initiate-,activities on  the
            part of the District Committees in the evaluation of  local  needs
            commensurate with the overall purpose of SCRMP.-  This section
            did publish a health data profile as a service and reference to
            project applicants and otherhealth care programs.

            Other sections of Core, excluding the Adrhinistrative and  Audit
            Sections, include the Section on Program Liaison,  Planning  and
            Evaluation and the Section on Communications both of which provide
            backup support for the other sections in the areas suggested by
            their titles.



            Regional Advisory Group:
           The RAG consists of 73 members, with the largest contingent (20 M.D.s)
           representing the 10 State Planning Districts and the second largest
           contingent (7 hospital administrators) representing the South Carolina
           Hospital Association.  While 13 other members represent 7 health
           and social agencies, 6 members represent 4 schools of higher learning.
           Aside from 2 nurses representing the Nurses Association, there is no
           other representation of allied health personnel.  14hile--there are 16
           member8-at-large, 10 of which are physicians, minority and consumer
           representation is not specifically identified.
           Committees:                                 Membership

           Executive Committee                             15
           By-laws and Nomination Committee                 6
           Heart Disease and Stroke Committee
           Cancer Committee                                13
           Related Diseases Committee                       6
           Education Committee             Unclear either   3, 22, or 32



           Subregionalization
           Medical District Committees are being established in each of the 10
           State Planning Districts as liaison groups with health planning agencies,
           general planning and development councils, and  professional  and
                                          ious districts.  These committees
           institutional groups in the var           eds which relate to the overall
           will be responsible for assessing local ne
           purpose and objectives of SCRMP.  they will also serve as a source
           of guidance for the RAG in promoting improved patient care in
                                                          sultation group  for
           categorical diseases and as a resource and con
           others in the district.





              South Carolina
              Regional Medical Program                                   RM  35-04  5/71


              Goals and Objectives

              The overall goals and objectives for the next triennium remain  the
              same as those established for the first three years of  operation
              with the exception that two new objectives have been added, 8 &  9.

               1. Emphasis on continuing professional education, utilizing
                  community hospitals in a region-wide program, and promoting the
                  expansion of the activities of the Medical University in this
                  area.  New medical knowledge would be provided to the practicing
                  physician through his community hospital.
               2. Encourage the development of Acute Coronary Care Facilities  in
                  community hospitals, and utilization of continuous  cardio-monitoring.
                  To reach this objective effective training of nurses and
                  physicians must be incorporated.
               3. Develop and support the existing State Aid Heart  Clinics  as
                  centers of excellence, not only for patient care, but to develop
                  in these continuing education of physicians, nurses, and allied
                  health personnel.
               4. Promotion of comprehensive care programs for stroke victims  in
                  community hospitals and also through the facilities of the
                  State-Aid Heart Clinics.
               5. Develop and study methods of population screening of risk factors
                  related to stroke, lschemic heart disease.

               6. Cancer program objectives should center around a strong  Cancer
                  Clinic System, with each Clinic serving as a center of excellence
                  for patient care and education. Cancer  Screening  services,  Patient-
                  oriented Tumor Registry, cooperative treatment  programs  are
                  specific objectives to be sought.
               7. Programs and studies to encourage and assist the efforts of community
                  hospitals and professional organizations to  develop  effective
                  definitions of job categories and more efficient  methods  of
                  patient care. Specifically, utilizing  in-service  education  programs
                  related to the care of patients with heart  disease,  cancer,
                  stroke, related disease as one method of approach, and  in  the
                  implementation of this to explore the effectiveness  of  audio-
                  visual aids in in-service education programs.

               8.  In the achievement of objectives, regional cooperation will
                   be sought between individual professionals, institutions,  and
                   organizations.

               9.  The full activiation of the 10 medical districts  should  be
                   carried out.





          South Carolina                      .712-             RM 35-04         5/71
          Regional Medical Program




                                                                                Recuested
                                          of departure, it would  appear  that  First Year
          With health manpower as a point
          specific developmental activities will emphasize: (a) new ways in     $125,000
          which the practicing physician can perform professional  tasks  more
          efficiently and reliably, (b) ways in which the non-medical tasks of
          the physician can be competently assumed by other professional or technical
          personnel,(c) ways in which new kinds of professionals can assist
          or stipport,the physician both in institutional and office  practice
          surroundings, and (d) improved information on the existing availability
          of health and health-related services in a given community, district
          or section of the region, or in the region overall.
          Proposed uses of developmental funds include:
             1.  Study needs and the organizational place for a Department.of
                 Community Health Services at the.Medical University.
             2.  Studies as to the regional need in respect to  specific  aids
                 in the promotion of health care services, such as; physician
                 assistant training programs, improved patient chart and
                 record methods, computerized patient records and health
                 service directories.

             3.  Studies in conjunction with applicant hospitals as to ways
                 by which strengthening of community hospitals can be achieved
                 through regional planning for services.
             4.  Specific needs identified by the categorical committees which
                 will necessitate developmental effort,- before  a  definitive
                 operational proposal-can be.developed.


          Second Year:  $150,000                           Third Year:  $200,000.





             South   Carolina
             Regional  Medical  Program           -13-                     RM 35-04  5/71


                                 PROJECT REQUESTS  BY PROGRAM SECTIONS

                               (related to map on page 24 and chart on page 23

             Heart and  Stroke  Section


             -Project #5A-Coronary Care Nurses' Training    Medical University       Requested
                          South Carolina                                             Fourth Year
                                                                                     $56,877
                          05 -  $58,035

                          (This project is a continuation of project #5 which was
                          supported for two years.  Project  #5A  which  was  approved
                          for 3 years has been funded in the current year with
                          carryover funds.  It has 04 and 05 year support)

             Objectives:  To continue a series of training courses that will provide
                          key nursing personnel for established or new coronary
             care units in hospitals throughout the state.


             Project #22 -Demonstration Service and Education Project in             Requested
                           The Heart Clinic - Medical University of South            First Year
                           Carolina                                                  $67,816

                           02-$ 52,86 7                03-$ 54, 311

                          (This is an approved but unfunded project)

             Objectives:  With additional staff new diagnostic procedures will
                           be added to the Clinic. tducational'and service facilities
             will be expanded to include inter-clinic  staff  exchange  and  telephone
             conferences, initial appointments to physicians not associated with
             heart clinics, and referral and consultation services on problem
             cases submitted  by  practicing  physicians.  Orientation  seminars  will
             also be conducted for paramedical personnel interested in heart-clinic
             activities and related programs.


             Project #29 - Comprehensive Care of Children with Heart Disease         Requested
                            Medical University of South Carolina.                    Second Year
                                                                                     $78,065
                           (This two-year project which is currently in its
                            first year of operation, is requesting committed
                            support for its second year.)

             Objectives: To develop  working  relationships  among  pediatricians  and
                          cardiologists through an exchange visit program set up
             between the Division of Pediatrics and the pediatricians in the community
             heart clinics.  To train nursing and paramedical personnel and to
             supplement the facilities and services of  the  Division  of  Pediatrics.

             Project #39 - Statewide Heart Clinic Education & Service Program -      Requested
                            South Carolina State Board of Health                     First Year
                            n?-@6A.son                       03-$73,500              $59,718




          South Carolina
          Regional !4edical Programs         -14-                  RM 35-04   5/71

          o             To train not less than 66 practicing physicians as
                        clinic fellows; to  conduct  semi-annual  seminars  for
          nurses and physicians  under  clinic  sponsorship  in  each  participating
          community, ultimately enrolling  in  these  seminars  30%  of  the  family
          physicians in the region:  to increase the number and capacity of heart
          clinics to meet local needs; to examine through a pilot program
          the  feasibility  of  establishing  subsidiary  clinics  for   specialized
          management of related disorders,  such  as  diabetes  and  renal  diseases;
          to establish a heart clinic patient registry.

          Project #58                                                       Requested
                                                                            First Year
                                                                   rolina    $106, 900

                         02- $115,645               03- $103,101.

                         (This  project  was  previously  reviewed  as  project  #35
                           and was returned for revision with the suggestion that
                           the  applicant  give  consideration  to  the  development
                           of other areas  besides  Charleston  and  plan  linkages,
                           design more  appropriate  in-service  nurse  training
                           programs with  educational  objectives  clearly  defined,,
                           and develop with the  proposed  curriculum  for  CCU
                           Training an evaluation  mechanism  designed  to  meet
                           objectives)
            Obiectives: To provide individualized  planning  for  coronary  care   in
                       each of  eight  unspecified   participating   hospitals.   To
            train nurses, physicians and other hospital personnel in cardiopulmonary
            resuscitation  and  coronary  care  thereby  providing  a  hospital-wide
            emergency resuscitation  plan  to  establish  a   communications   system for
            EKG transmissions and consultation  which  will  link  participating
            hospitals to the CCU at the Medical University.  To establish a patient
            registry designed to provide  adequate clinical material for evaluation
            of therapy and programs.
            roject #40 - Stroke Nursing     Medical University of South            Requested
            p
                           Carolina.                                               First Year
                           02-$61,262             03-$64,243                       $62,154
            Obiectives: It is hoped that by  training  a  cadre  of  nurses  in  the
                         care of  stroke  patientsother  areas  of  the  state  will be
            able to provide better nursing care  for  the  stroke  patients  and  for
            patients with similar nursing problems.  The College of Nursing will
            offer an educational program  for  nurses  throughoutthe  state  in  the
            care of the stroke patient.  A series of courses are to be conducted
            at Columbia for the ensuing three years.  Four sessions of two-weeks
            duration are to  be  offered  per  year.  The  Columbia  Hospital  Stroke
            Demonstration Unit will  be  available  for  clinical  experiences.





              South   Carolina
              Regional Medical Program             -15-                    RM 35-04  5/71

                                                                                 Requested
              Project #41 -  Central Midlands Early Stroke Detection             First Year
                             Project - Columbia Hospital.  This                  $148.,928
                             appears to be an extension of Project #15 -
                             Stroke Management Demonstration and Project #16-
                             Stroke Recovery and Rehabilitation, both of which
                             were supported for the first 3 years of operation.
                             02-$148,928                      03-$148,928
              Objectives: Through a series of lectures throughout the region by the
                           project director,physicians will be persuaded to  spend
              a period of  concentrated stroke training time in Columbia  Hospital.
              Following training they will return to their locale where  they  can
              contribute to stroke programs in their community hospitals.  In
              addition, nurse and lay and allied health personnel stroke education
              will be provided by the project.

              Project #42    Implementation Program of Heart And Stroke- Projects -  Requested
                             South Carolina  Heart Association                      First Year
                                                                                     $99i626
                             02-$117 208              03-$118,139

              Objectives:lhe proposed activities will provide region-wide implementation
                           of d series of community projects. Activities  will  be
              implemented by a Program Implementor, a staff member who combines close
              familiarity or topical expertise in specific project areas with skills
              in applied behavioral science. Three project  implementors  will  be
              appointed and will provide the needed linkage between projects developed
              by the Heart Association or other agencies at the  state  level  and
              community-based volunteer project leaders.  They will receive specific
              training in current aspects of health-cake delivery and in behavioral
              science techniques.
              Project #43 - A Regional Program for Improved Diagnostic and        Requested
                             Therapeutic Management of Hypertension - Medical     First Yeat.
                             University of South Carolina                          $40,564

                              02-$41,793              93-$43,082

              Objectives: Project components include: 1)  immediate  provision  of
                           technical assistants to develop steroid assay and  renin
              assays at the Medical University; 2) establishment of regional facilities
              at major medical centers (Columbia, Spartanburg, Greenville an
              Florence to assist in disseminating information and to  provide  for
              the screening of hypertensive patients to facilitate selection of those
              in need of further study; 3) systematic demonstration of current diagnostic
              approaches and their interpretation to physicians  through  lectures
              4) provision of careful follow-up for patients so managed through detailed
              records.


              Cancer   Section

              Project #13R - Central Midlands Gastro-Intestinal Disease          Requested
                              Detedtion and Traini@ - Columbia Hospital          First Year
                                                                                  $45,808




         ..,-)uth Carolina
         Regional Medical  Program           -16-                 RM 35-04   5/71


            This is a one year renewal request for an ongoing project which
            is in its third and final year of support.



         Ob.iectives:  The community hospitals and patients in the Midlands
                   .  area of the state will be offered a full range of diagnostic
       .procedures directed at diseases within the gastrointestinal tract and
         abdominal cavity.  Educational facilities in the Gastro-intestinal
         Clinic will provide for teaching of physicians and technicians.


         Project #44   Florence Cancer Clinic Education and  Service      Requested
                       Program   State Board of Health                    First Year
                                                                            $49,908
                       02-$50,032            03-$51,809
         Obiectives: Utilizing the structure of the Pee Dee Cancer Clinic this
                     project would up-grade the education of physicians by
         making a formalized educational program available through:

            1) weekly clinic teaching sessions with audio-visuals
            2) consultation
            3) tuedical education network
            4) annual seminar
            5) reference  library.


         Project #45   State-wide Continuing Education in Nuclear Medicine     Requested
                       Self Memorial Hospital                                  First Year
                                                                               $68,785
                       02-$60,649                   03-$130,106
         0           A four-element educational  program  designed  specifically
                     to close the existing health care gap in Nuclear Medicine
         will be initiated and will consist of: 1) nuclear medicine technician
         training, 2) physician's continuing education program, 3) annual
         symposium, 4) lecture and consultation program.  A Gamma Counter is
         to be purchased in the 03 year for approximately $77,500.


         Project #46- Hematologic Ma             Education and Service         Requested
                       Program for South Carolina   Medical University         First Year
                       of South Carolina                                        $81,913

                       02- $84,228                  03- $95,570


         Objectives:  To establish an ongoing postgraduate training program in
                       hematologic malignancies for physicians  and  technicians
         of South Carolina through the establishment of a Leukemia-Lymphoma Center





              The South Carolina Regional
              Medical Program                                          Rm-35-04    5/71
                                                  -17-


              and an extensive education program consisting of the following:

                1) Leukemia-Lymphoma Center Programs
                2) Quarterly Demonstration Seminars
                3) Programs utilizing Pediatric Cancer Networks
                4) Consultant Services
                5) Lecture Series
                6) Annual Conference

              Fellow Hematologists will be supported by the project.


              Project #47 - Coordinated Application of Clinically Proven            Requested
                            Procedures To Reduce      lications Fol    in           First Year
                            Radiotherapy to Head and Neck - Medical University        $30,271
                            of South Carolina.

                            02-$33,905                 03-$35,746

              This project has been reviewed and rejected two  times  by  the  National
              Advisory Council. The last reason for  rejection  was  that  it  appeared
              excessively expensive (01-$116,520, 02-$94,509, 03-$99,509), too centralized
              and appeared to be basically the establishment of a Head and Neck Clinic
              with minor emphasis on continuing-educatibn.

              Objectives: To establish methods of management of  the  teeth  and  their
                          supporting structures which will  provide  the  best  prophy-
              laxis and lowest incidence of complications in patients recieving radiation
              therapy of the oral cavity.  Professional education will consist of
              seminars throughout the state during the second and  third  years,  for
              physicians, nurses, dentists and allied health.  Treatment an
              followup will be provided to all patients regardless of economic
              status or race.  The project will broaden the scope of the MUSC
              Dental Clinic and the State and Cancer Clinic System as referrals will
              be made to the medical University from these clinics.


              Project #48 - Cooperative Gynecological Radiotherapy Program          Requested
                            in South Carolina - Medical University of               F-rst Year
                            South Carolina                                          $240,165

                            02-$201,633            03-$227,836


              This Iproject appears to be an expansion of Project #10    Carcinoma   of
              the Cervix which has been ongoing for three years  and  was  designed  to
              inform physicians regarding carcinoma of the cervix and screen indigent
              patients.

                   tives: To establish in South Carolina a cooperative team approach
                          to the total management of the-cancer patients from
              primary family physician to the Oncologi8t and associated allied health
              personnel.  Training programs, consultatio4,and treatment planning services




               Carolina                         -18-
         Regional Medical Program                                     RM 35-04  5/71


         at the Medical University will be established to augment the
         expertise and knowledge of the physicians in the local community.  This
         program will be coordinated with other cancer  projects  in  the  state
         for optimal effectiveness in meeting objectives.    Fifty percent of  the
         first year budget is devoted to equipment.

         Related Disease Section

         Project #55 - Hemodialysis Continuing Education Program          Requested
                       Medical University  of  South  Carolina            First Year
                                                                          $65,194
                       @2-$69,914           03-$76,881


         This project appears to be a continuation and expansion of ongoing
         Project #18   Hemodialysis Continuing Education which:-.was designed  to
         establish a hemodialysis center at the  Medical  University  and  offer
         training for medical and paramedical personnel.


         Objectives: To continue a hemodialysis  demonstration  center  as  a
                      means of continuing education for nurses, and    allied
         health.  Through continuing education courses  and  seminars
         involvement of professional and lay personnel  on hemodialysis
         will  increase.
         Project #56   Comprehensive Respiratory Disease Training Program      Requested
                       Medical University  of  South  Carolina                 First Year
                                                                               $179,487
                       02-$93,156              03-$196,361
         This project has been reviewed and rejected two times by the National
         Advisory Council.  The last review recommended a site visit to collect
         additional information and clarify points.
         Obiectives: Coordinated through a central  laboratory unit to  be established
                     at the V.A. or the Medical University Hospital, the project
         will offer:
            1) Structured demonstration lectures and refresher courses at the
               central unit.
            2) Visiting Lecture Series to be presented in every county of the state.
            3) Invitational Consultation services for establishment, improvement,
               maintenance or operation of hospital-based facilities.
            4) Annual seminars-s@ummarizing latest developments and techniques
               in the field.
            5) A data transmission network offering  patient  diagnostic  and
               managetent-consultant  services.  Through  direct   linkages
               between hospital-based equipment and  central  unit  computer.
               There is a large $89,529 equipment re uest  the  first  year  and
               an $80,000 equipment request  the  thirl  year.






               South   Carolina                     -19-
               Regional  Medical   Program                                       RM  35-04   5/71



               Education Section
                                                                                      Requested
                                                                                      First Year
               Project #31 -  Demonstration Project in Contin         'Education      $62,700
                               in a Community Hospital - Spartanburg General
                                 Hospital.

               This project which has been approved  for  3  years  has  been  funded  with
               carryover funds in its first  two  years  of  operation  (01-$22,707,  02-
               $11,550). It is approved for  a  third  year  of  support  at  $28,947  this
               project relates very closely to project #57.

               Objectives:  To demonstrate the value of a broad, progressive, community
                             hospital-based continuing education program to medical
               services areas.  It would develop close cooperation with the Medical Uni-
               versity.  Methods  would  include;  varied  educational  programs   that
               will  actively  involve  the  medical  professional  community  organization
               of an adequate  administrative  staff  for  the  Office  of  Education,  expansion
               of cooperative programs with the Medical University, and implementation
               of effective  rotation  of  Wofford  College  students  On  various  professional
               services of the Spartanburg General Hospital.


               Project #49  -  Statewide  Laboratory  Personnel  Refresher            Requested
                              Training - South  Carolina  State  Board  of            First Year'
                              Health                                                  $32,470

                              02-$25,094                  03-$25,7-49

               Objectives:  To   establish a statewide program to upgrade the diagnostic
                            acumen of laboratory  technicians  in  all  hospitals,  to  establish
               a facility where Dhysicians, nurses.and allied health professionals
               receive refresher courses on the latest techniques and procedures avail-
               able for diagnosis of disease, to establish a mobile laboratory equipped
               for teaching which would be  taken  to  any  size  hospital  to  provide
               refresher training for laboratory technicians.  First-y6ar budget includes a
               requestof$12,000 for a  mobile  unit  and  16  microscopes.

                                                                                      Requested
               Project #50 - Central Midlands Medical Education Program -             First  Year
                              Columbia Hospital                                         $129,118

                              02- $117,706                  03-   $122,899

               Objectives: Establish a region-wide continuing medical education program
                            aimed  at all physicians, nurses and allied health personnel
               in the Midlands area  (4  counties).  On  a  continuing  basis  analyze  the
               region's  physician,  nurse  and  allied  health  personnel  population,
               their distribution,  specialities,  and  need  for  continuing  education.
               Develop a curriculum consisting of  courses  and  subjects  aimed  at  the
               areas educational  needs.  Plan  demonstrations,  conferences  and  ot  er
               teaching  experiences.  Involve  teaching  resources  of  other   hospitals.



                Carolina                    -20-                    RM 35-04 5/71
           Regional Medical Programs
                                                                             Requested
           Project 51                                             lth        First Year
                                                                  Allied     2@52,739
                                                                  outh
                                                                  n)

                       027$228,301                03-$231,983
                      The development of a satellite studio;sponsored and
                      operated jointly by the South Carolina Education TV
           Network and the Medical University which will  permit  the  production
           and broadcast of both live television programs or taped  programs  on
           the campus of the University.  An important adjunct will be the
           utilization of two-way telephone communication  over  the  Tele-Pac
           Telephone System so that teachers and students will be able to   have
           vocal communications,throughout the period of  visual  presentations.
           Development of continuing education centers in the community
           hospitals.  Large equipment requests are made for each of
           the 3 years. (01-.$105,163, 02-$45,500, 03-$30,300)
                                                                               Requested
                                                                               First Year
           Project #52   Health Manpowbr Project - South Carolina Hospital     $68,115
                         Association
                         02-$70,695              03-$74,500
           This project appears to continue and expand Project  #20  -  Health Education
           n,da RKecrulitLmueinLt- which is in its third and final year  of  support.
                      Working within the 10  health  planning  districts,  the project
           Objectives:
                      will seek the  support  and  cooperation  of.the  planning
           district groups, especially the health planning groups of each
           district. A training program will be initiated in each district whereby
           previously gained knowledge will be utilized to train various people
           who can staff exhibits and fairs, as well as serve  as  the  speakers
           bureau  The project staff  together  with  the  Hospital  Association
           will continue its cooperative efforts with educational institutions.
           Project #53 - Information Network for Medicine - Medical            Requested
                         University of South Carolina                          First Year
                                                                               $71,587
                         02- $105,417          03- $111,177

           Obiectives: To design, implement, and operate  a comprehensive medical
                       pharmaceutical information system.  This will be done by
           installing and utilizing a direct telephone line to enable any
           physician, dentist or pharmacist or emergency room to merely reach the
           nearest telephone for direct access.  The line will operate 24    hours
           a day, 7 days a week.  Computer costs go from 4,900 the first year to
           26,100 the second and 28,100 the third.





             South  Carolina
             Regional Medical Program           -21-                   RM-35-04  5/71


                                                                               Requested
             Project #54 - Planned Discharge an@j'@@c@5@                       f,irst Year
                           tion Project - McLeod Infirmary, Florence.

                           02-$41,830                03-$45,613

             This project was previously reviewed by the National Advisory Council
             and disapproved for RMPS support because it was too comprehensive in
             nature and did not adequately relate to the categorical- diseases.

             9@-c iv@es: To promote comprehensive and continuing inter-related  patient
                          care for patients with heart disease, cancer, stroke  and
             related diseases, through coordination and efficient  utilization  of
             community resources.  Project staff will comprise a three-member
             health team to provide useable information and to coordinate community
             resources which will cut down on. patient costs, by providing  faster
             convalescent care.  Recognizing the needs of the patient, the physician
             and the acute general hospital, this team will develop necessary
             techniques for liaison, planning and related educational projects.


             Project #57 - Continuing Medical Education @rogram for             Requested
                           Physicians Nurses and Allied Medical Personnel -     First Year
                           Spartanburg General Hospital                         $100,850

                           02-$79,793                      03-$82,883

             This project appears to relate directly to project #31     Continuing
             Education in a Community Hospital which is sponsored by the same hospital,
            has been supportedwith carryover for two years and is  now  requesting
             third year  support



             Objectives: To foster cooperation among physicians, nurses and
                         allied health personnel in the development of  the  "Team
             Approach" concept of preventive and comprehensive medicine.  To
             test the feasibility of training allied health personnel  toward  the
             physician in his daily routines.  To recruit and train allied medical
             personnel concerned with rehabilitation.  To develop new and
             innovative techniques to bring medical information to  the  community
             hospital.





                                                               C U i -1 I!-! "i@ T'- Y                    i: E D  B Y
                                                                   SO-LilcH

                                                                                           Future  years                                Funded  (d.c.)   11  MO
          Project        Title        and         Nuinber                                    of  Support                                        8/i/70    6/30/71

                                                                                                   2                                                     $456t498
          Core
          #6-Spartanbur.@F              t               Clinic                                     0                                                 24,179

                                                                                                                                                     25,017
          #7-Florence            Heart             Clinic                                          0
          'W'8-Gatdiopulmonary  Resusditatio-,i                                                    0                                                      @40,341
             Tra@n
          #9-Tri-County  Cervical  Cancer                                                          0                                                 91,227
             Scree-@iin?,


          #10-Ooopcrative             ProRram             on
               Carcinoma        oj'        the        Cerv'A-x                                     0                                                      172,287

          'w@12-Pcdiatric  Cancer  Education  and
               Serv3.ce                                                                            0                                                 93,444

                                                                                                   0
          1    C,                                   Tract
          3,-     -inc - r   of G.I.                                                                                                                 27,941

          @1r)-Stroke                              Der,,,oiisttat4-on                              0
               ii)       i       Co,-,.nLinjtv        Hospital                                                                                       7 0, f-)   9

          7't'16-rk,@@ional  Stroke  Re.-ial)ilitation                                           0
               and  J'rea-ui.@t@nt                                                                                                                   30,931,-

                                                                                                 0                                                          4,183

          2 0                                            ReCrU4t,@-!i,!- Pr  @ct                 0                                                   52       @48

          #5A-Co;                                       Tr,@,ini-ci
                     V@@i:sitv. O-L@  Scuth  Ca-.coliilp                                         0                                                   39,367

          2 5  -           I   T   r,,. o r  @i,:, -s      r@                                    0                                                   23,-")13
                                   Rn6iati-on           I  e 7-@t),t                             0                                                   5"-,338

                                           @',,3re  of  Ci@l.di-en
               i7.
                                             E." t2,i r    D


                                           of
                         C@ll-lil@i-,:t-.y  i'kosi-)itai.                                        0                                                   11,550
                                                                                                                                                       $1,292,791
          As  a  result        of  the  Director's  recent  cut-l-ack  on  all   regions,  SCRNP's  surport
          For the current vear will be reduced to $1,200,225. Adjusted budgets have not
          as yet been received by RMPS.











                                                                                                                                              -23-
                                Total Request $2,991,048  (d.c.)
                                                                               Rei,n _South Carolina                   RM 00035
                                Breakout of       -,(:)@MP Request for.the up            comii-ig Year 7/71-6/72             by Category and
                                  Type of Act]-vity.



                                                                                                                                Co@IIIC'IF.NTS BY l'i!,E OF ',CTIIJITY
                       CO:JP(@,:K@FS PY DI-@EASE   C."' ':GORY
                                                                                                                           TRAII,IZG Al@D F.DUCATIC',i
                .,;iF,ART
                           0   Projects       5                                                                                       Projects  18
                                                                                                                                    Total $S       1 77 0, 92 9
                           T@,ti)l   369,376
                                                                                                                                   % $S            59%
                           %  $s  127




                     C,\4CER
                           I'  Projects       6
                           Total $S           516,850                                                                       I)v,,Io,,S'IPATIC'4 OF F,,ilE'NT CARE
                           %  $S              17%
                                                                                                                                       Projects    1
                                                                                                                                    Total $s 67 816
                                                                                                                                    % $S        2%



                           li   Projects      2
                           To,@al $S          211,082
                           1. $S              7%
                                                                                                                             RESEARCH &

                                                                                                                                        projects      2
                     !KIDNEY                                                                                                         Total $s 113
                                                                                                                                     % $S           4@
                                Projects
                           rotal $s 65,194
                           1.  $S  -         2%




                                DISEASES
                                Projects                                                                                ADIIINTS'fOA'rION & PTA,'4141"'G
                            total SS 226,051                                                                                    1 Projects      Core        4
                            % 5s7%                                                                                              Total $S  913,380
                                                                                                                                7. $S       31%


                                      CC.@ICAI,

                                rrijcct@s'    1
                                     $1  99,6:                                                                                             al.  Coinponent
                                Ss     37
                                                                                                                                           00



                        CEI:.'RAL

                             ?i Projects  Core t  8
                                      $S      1 383 869
                             %   $s    46%



                                  Developmental Component
                                       $125,000
                                4%



                                          GEOGRAPHIC SCOPE OF PROPOSED PROJECTS FOR 04 YEAR
                                                             7/l/71-6/30/72


                                               #31-Cont. Ed. in Community
                                                    Hospitals (Spartbg. Gen. Hosp.)
                                               #57-C.E. for Physicians-& Nurses
                                                    Spartbg. Gen. Hosp.)
                                                                                               l@44-Florence Cancer-C.E. & Serv.
                                                                                                   (Board of Health)
                                             ';LLE                                            #54-Planned Discharge & Care
                                                                    YORK
                                                                                                   (McLeod Infirmarv)
                                                 5pARTANDUR

                                          Az.
                                                                                          ESTERFIELD@
                               NEE                                 CHESTE'R'

                                      ER50H
    ii-Midland Stroke                                  4 5                                   DAALINGTO
                                                                 \  FAIFkriELD
      Detection (Columbia


                                             ILLE )Gfl                                             RENCE
          land Gastric In                                                                                MARIO
    @3R-Mid
       Disease  (Columbia   Hosp.:
    iO-Midlands Med.  Ed.  (Colum,
                                                         5ALU A
                                             c@
    REGION-W IDE PROJECTS
    l@5A-CCU  Training  (Med.  U.)
    #29-Children   Heart   Disease (Med. U
    #40-Stroke  Nursing  (Med.   U.)                                                                          WI
    #43-Diagnostic   &   Therapeutic
        Hypertension   (Med.   U.)                                          ORANGEU;
    #46-Hemotologic     Malignancies Ed.                                                     BEAK
                                                                                              0.
        and  Services  (Med.   U.)                                ELI
    #48-Gynecological Radiotherapy     (Med.U)
    #56-Respiratory  Disease  Trng.(Med.   U.)
    #53-Information Network (Med. U.)
    #39-Heart Clinic Ed. (Board Health)
    #42-Implementation of Heart & Stroke
        (Heart Association)                                                                                              Heart
                                                                                                  #22-Dem. Serv. & Ed.
    .#45-Cont-. Ed. in Nuclear Med. (Self                                                             Clinic (Med. U.)
        Mem. Hosp.-Greenwood)
    #49-State-wide Laboratory Trng. (Board of Hlth.1                                              #58-Coronary Care Coastal
                                                                                                      Hosp. (Med. U.)
    #52-Health Manpower (Hosp. Assoc.)                                                            #47-Complications of Radiotherapy
                                                                                                      to Head & Neck (Med. U.
                                                                                                  #55-Hemodiolysis C.E. (Med. U.)
                                                                                                  #51-C.E. for Heart Profe,        ls
                                                                                                      & Allied Health Peo.P




                                                                   (A Privileged Communication)


                                  SUMMARY OF REVIEW AND CONCLUSION OF
                                       APRIL 1971 REVIEW COt@t4ITTEE

                                SOUTH  CAROLINA REGlOi4AL MEDICAL PROGRAM
                                            RM 00035-04  5/71,

                           FOR  CONSIDERATlUil BY MAY 1971 ADVISORY COUNCIL


              RF,CO@fFNDATIOLNS:  Committee recommended that the Region be awarded
                                  $1.5  million  dollars  (direct  costs)  for  each  of   three
                                  years including developmental component funding,
                                  The Ad Hoc Renal Disease Panel recommended Project #55'-
                                  Chronic Renal Disens-e- Education and Servi-ce be deferred
                                  for a site visit.

                                                                             RECO@ZIENDED   FUND
                                        R@Ur,- T@(PD@irect Costs)                (Direct Costs)
                                  Fourth           Fifth        Siyth           Each  of   Three
                                   Year            Year         Year                 Years
              CORE              $  615,490     $   6500035    $    679,538           500,000
              PROJECTS           21250,558        1,927,4.01  .2,114,417             900io0o
              DEVE, LOPIE-,NTAL @2 5 O@O 0         150.000         2001-000          100.000
                 TOTAL          $29991,048   -    $2,727,436  $2,993,955           $1.,500,000
                 Note:  Support of Proj-ect #52 - Health      M@inp         'precluded
                                                                  _2i,7tr is
                         by IZ14PS policy  which  states  that  RMP  grant  funds  are
                         not to be used for direct'operational. grant support
                         of Health Careers Recruitment Projects.




              Funding Recommendation      is  basically consistent-with.that of the site
                                          visitors.  However,   while   the   visitors   had
              recommended $1,127,041 of proi               rt for each of three vearso Committee
              believed  the  project  level  should  be  reduced  to:$900,000   which   provides
              for  a  more  modest  growth  over  the  current  level  of  support.  Also  taken
              into consideration was t,ie fact'that a number of projects.orc requesting
              large equipment and personnel items which are inappropriate         . at-thi. s- @    -1
              time  when  R@  funds  are  extremely  limited.  Project  #5A  -   Coronerv   Care
              Ilu-             at  the  lledical  University  was  cited  in  particular  as
              requesting  excessive  personnel  wlio,in  facttwoul.d  apkar  to   be   providing
              patient services.
              Pt6grbm Observations:  Committee concurred with the site visitors report
                                      , which concluded that while the Region has not
              demonstrated  outstanding  maturity  or  quality,  it   his   made   substantial
              progress during ita first three years of operation,  (,iven the limitation,-,
              of categorical disease and continuing education under which the Region
                                                       C)
              initiated its first tlirce-year operational plan, #the limited resources







             SOUTH CAROLINA RI.IP                                               RM   00035


             of the Region, and, the. skepticism with which niiny    health   provide rs viewed
             R14P, the Region appears to have been moderately successful in focusing
             its rrojects on some  of  the  major  problems  of  South  Carolina.  ,It  has
             concentrated  through  continuing  education   programs,   some   involving
             state-aid clinics,'  to  upgrade  the  knowledge  of  the  rural  physicians
             who in most instances. have not kept current with modern procedures related
             to heart,  stroke  and  caiicer.  In  addition  through  the  coronary  care
             training projects, the stroke and cancer projects, SCR14-P,has succeeded
             in  improving  facilities  and  services  in  rural  communities,  most  of
             which are medically deprived.

             The activities promoted by 8CIU@iP  have  also  served  to  remove  much  of
             the sikc-pticism-miny of the S.C. physicians harbored  about  Rl,,4P  and  it
             appears SCRI,.T through al.1 aspects of its  progreii  has  succeeded  to  a
             large degree to Ilive won the confidence of the various health interests
             of the t,.ic-dicnl conrriuziity.  The lledicel University i@71iicli prior, to SCRI-11"
             was a classic example of an "ivory toil-<@r" is now extending itself thrott,,h
                                                                            0
             many of the projects into the                   touch of the  success  of  the
             program-appears attribtita'ol.(, to the leadership  of  past  niid  present
             Provrarn Directors, cap,2b].e Core Staff (particularly the three associate
             coordinators),  active  RkC  Chairman  and  the  interest  and  dedication  of
             the, RAG membership.


             The Reviewers  noted  that  the-program  as  designed  for  the  next  three
             years remaiii-s  highly  categorical  and  will  be  implemented  primarily
             through  traditional  continuing   education   activities.   However,   they
             reasoned that the  Region  has  generated  a  degree  of  momentum  in  the
             direction that can not  be  abruptly  changed  and  that  at  the  time  this
             application was  being  drafted.,  the  new  and  broadening  philosophies  of
             R@IP bad not yet emerged.

             Wliilt Committee  members  were  for  the  mcat  part  favorably  impressed
             with the South Carolina RI-[P,  they  agreed  with  the  site  visitors  that
             the following  aspects  of  the  program  are  areas  of  needed  strength4
             They also fel@t that white these observations  tiere-,  conveyed  to  the
             Region at tl-te time of  the  visit,  they  should  be  reemphasized  and RIIP
             staff should offer assistance and monitor progreca.

                  1.  The  program  remains  basically  categorical  and   educati@onal-
             in nature,  thereby  disqualifyin-  some  of  the  more  serious  disease
                                               t7
             problems of the Region and limiting the types or
                                                                 .   imaginative   projects
             generated for their solution.

                  2    The composition of the RAG is unbal.-iiiccd  and  'heavily  in
             favor of the M.D.s  and  14edical,  Society  interests.  Also,  there  is
             under-represcntation of all.fed  health  interests  and  the  Pal-aietto
             Me83'-cal Society.






             SOUTP, CAROLINA RMP                                                R@l  00035


                   3.  Whil-c the Region's overall    goals and objectives    are   more
             specific than most, there is a need      for  them  to  be  identified  in
             more  specific  and  measurable  terms  or  to  establish  more   specific,
             sub-objectives.  Also,,they should be more closely related to
             flassessed needs'.

                   4.  Core Staff has functioned to date      more  as  a  catalyst  to
             persons iiho  have  had  projects  they  wished  to  have  funded,  rather
             then as a stimulator of projects designed       to meet specific objectives.

                   5.  While the SCRI,@IP has taken positive steps to improve project
             evaluation, program evaluation needs additio,,iil -@,.trengtlic-riirts.bcginiiing_
             viitti measurable

                   6.  Although rn?l)ort       bc-en est@il)li,-ht-(l @.7itl-i the C)r!,O, I.,Iodel
             Cities, and Appall-chin Agencies, there is a n(-@,.@(I for closer  i-7orki.ng
             relatio-.ichips and coordinated I,)l.annit-.g.
             effect Y155  -  Chronic  Renal  Disease  Educ@t:ion  end  Service  Program  -
                             did not receive n technical. ':revie-@-i by Committee, but
             rather v7as deferred for such  a  review  to  the  Ad  FLoc  Renal  Disease
             Panel iihich met the  following  day.  While  the  Piiiel  fel.t  the  Region
             had done yeoman service in developing needed renal services 1,7ith sm,,,)].i
             financial. nstintrinec, it b6lic-,rcd finnl action t-.botild be deferred pending
             a ,iito visit to provide assistance in reduction of certain ispects of
             the program to prevent proliferation.  It was al.so belived certain
             budget items v7ill need to be redirected, but will not eicced the qniount
             of the original. rtqueats,
                   Nott-   (Staff-is concerned that this recommendation for
                           deferred action crentes  a,probic,,ni  in  that  Project  #55
                           is an  extension  and  @:pansion  of  ongoing  Project  i7l8
                           and such action will interupt the continuity and
                           transition of the program.)


















                                                                    GR]3/1@Z,IPS/li 23/71.







                                          DEPARTMiEN'r o@                       EDUCATIC)NI /@i4D '4%"ELFARE
                                                                  t--oal-IC FiEAL:I-Fl SERVICE
                                            HEALTH SERVICES AND MENTAL HEAL.Tt4 ADN41,,iiSTRATION


                        March 23,  1971

         P."bly to

           Subject:     Quick Report  on South             Carolina Site Visit                 March  16-17,  1971  (Charleston)

               To:      i-rector
                        Regional Medical Programs  Service

                        Through:   Acting Deput   Director
                                                           y
                                     - Regional Medical Programs  Service,


                        The site visit  team consisted of:

                                        Edmund Lewis,  M.D.  (Chairman)
                                        National Review Committee


                                        Bruce Everist,  M.D.
                                        National Advisory Council

                                        William Stoneman,  M.D.
                                        Program Coordinator - Bi-State @IP

                                        Russell Lewis,  M.D.
                                        Practicing Physician                 Marshfield Clinic,  Wisconsin



                        RMPS  STAFF:

                                        Veronica Conley,  Ph.D.  - Continuing Education
                                        Lyman Van Nostkatd - Program Planning and Evaluation
                                        Frank Nash - Regional Development Branca
                                        Ted Griffith            Regional Offite Representative
                                        William Reist             Grants Review Branch
                        Representatives  of  the Region included past  and present RAG chairmen,
                        a broad spectrum of RAG members,  the Program Coordinator and most
                        of professional  Core  Staff,  including  field  representatives.
                        it was  the  feeling of the site visitors  that  this  Region has,made
                        substantial progress  dur@;,.n,-  ,.ts  fi-rst  thtell- years  of operation.
                        Given the limitations  o   categorical diseases  and  continuing education
                        under which  the Region initiated its  first  tl-iree--vear operational
                        plan,  it  appears  to have worked within its somewhat broadly stated
                        objectives,  to focus  its projects  on some of  the major problems
                        of the Region.    It has  concentrated through continuing education
                        pro rams,  some involving state-a-l-d clinics,  to  upgrade  the knowledge of
                                                                                     nees  is  servino@  large numbers
                        the rural physician who  in most insta
                        of  relatively poor,patients but'has  not kept  current with modern
                        medical procedures  related  to heart,  strol,(--  and cancer.







              Directo  RMPS      -e 2
                     r



              In addition through the coronary care training projects,  the  stroke
              And cancer projects, SCPM    has succeeded in improving  facilities
              and services in the rural communities of which most  are  medically
              deprived  areas.

              The  activities promoted by SCRNP have also served to remove much  of
              the  skepticism many of the S.C. physicians harbored about RNP
              and it  appears SCPM through all aspects of its program has
              succeeded to  alarge degree to have won the confidence of the
              various  health interests of the medical community.  The Medical
              Univ6rsity which prior to SCRMP was a classic example of  an  "ivory
              towet" is now extending itself through many of the  projects  into
              the hinterland.  Much of the success of the program appears attributable
              to the leadership of past and present Program  Directors,  capable
              Core Staff, progressive RAG chairmen and the interest and dedication
              of the RAG membership. All are, strongly motivated and  appear  to
              be contributing to the'total strength of the programi

              While the visitors were favorably impressed with the  direction  and
              success of the program during the initial three years  of  operation,
              they identified the following aspects of the program as  areas  of
              needed strength.

                        1.  The program remains basically categorical and
              educational in nature, thereby disqualifying some of the more serious
              disease problems of the Region and limiting the types of imaginative
              projects generated for their solution.

                        2. The composition of the RAG is  unbalanced  and  heavily
              in favor of the M.D.s and Medical Society  interests.  Also,  there
              is under"representation of allied health interests.

                        3. While the Regionts overall goals  and  objectives  are
              more specific than most, there is a nbea.for them to  be  identified
              in more specific and measurable terms or to establish  more  specific
              sub-objectives.  Also, they should be more closely related to assessed
              needs.

                        4. Core Staff has functioned to date as  a  catalyst  to
              persons who have had projects they wished to have funded,  not  as
              a, stimulator of projects designed to meet specific objectives.

                        5. While the SCRMP has taken positive  steps  to  improve
              project evaluation, program evaluation needs additional strengthening
              beginning with measurable objectives.

                        6. Although rapport has been established  with  the  OEO,
              Model Cities, and Appalachia Agencies, there is a need  for  closer
              working relationships And coordinated planning.








           Director RMS     Page 3




           RECO@NDATION:

                   1.  Approval of Cbre,at.               $500,000

                   2.  Approval of project support
                       at:                            $13, 127,041

                  3.   ;Approval of developmental
                       !component at:                     $100,000

                                         Total           1,727,041














                                                      William S. Reist
                                                      Public HeAlth Advisor
                                                      Gtants Review Branch




                                                                (A Privileged Communitation)
                                                                       RM 00001



                                         SITE VISIT REPORT
                               SOUTH CAROLINA REGIONAL MEDICAL PROGRAM
                                        March 15-17$ 1971
                                     (Charleston, South Carolina)

              SITE VISITORS
              Edmund J. Lewis, M.D.,, RMPS (Review Committee), Site Visit Chairman
              Bruce W. Everist, M.D. (National Advisory Council)
              Russell Lewis, M.D. (Practicing Phys) Marshfield, Wisconsin
              William Stoneman, III, M.D. (Program Coordinator) Bi-State RMP
              Veronica Conley, Ph.D., Continuing Education Branch
              Lyman Van Nostrand, Program Planning and Evaluation Branch
              William Reist, Grants Review Branch
              Theoda Griffith, Regional Representative, Region IV
              Frank Nash, Regional Development Branch


              SCRHP PARTICIPANTS (In Alphabetical Order)
              Dr. E'Kenneth Aycock, State Health Officer, S.C. State Board of Health, Columbia
              Dr.@ Waddy G. Baroody, Assistant Coordinator for Regions VII and VIII, and a
              Practicing Physician, Internist, from Florence
              Dr. John P. Booker, Pregident-Elect of the S.C. Medical Association, and a
              Practicing Physician from Walhalla
              Mr. C.W. ("Pete') Bowman, Associate Coordinator, SCRKP Section on Medical
              Districts Programs Planning
              Dr. Rembert 0. Burgess, Chairman, Heart Disease and Stroke Committee'of
              the RAG, A practicing physician, Internal Medicine and Cardiology, Spartanburg
              Dr. James W. Colbert, Jr., Vice-President for Academic Affairs, Medical
              University Of S. C., Chairman, Regional Advisory Group
              14t. J. Walker Coleman III, Director of Program Liaison, Planning And Evaluation
              Section, 9CMQ
              Dr. G. Preston Cone, Representative of the Medical Districts Committee, a
              Practicing Physician from Orangeburg
              Mr. James M. Daniel, Assistant Coordinator for Regional Development, Regions
              IV' V and VI Columbia SCRNP Staff member
              Mr. Stephen P. Dittmann, Chairman of the Dept. of Audiovisual Resources of
              the Medical University of S.C.
              Mr. James Dom, Assistant for Educational Communications, Section on
              Continuing Education, SCRMP Staff
              Mr. Fred Ellison, Administrator, York General Hospital, Rock Hill, S.C.
              Mrs. Esther Fields, Member at Large on the Regional Advisory Group, from
              Columbia, a Consumer
              Mr4 William B. Finlayson, Co-Chairman of the Reg.ional Advisory Group;
              Administrator of the Conway Hospital, Conway, S.C. and Board Member  of
              the S.C.           Association
              Mr. Luther Haynie, former member of the Regional Advisory Group, member,
              S.C. Chapter, The American Cancer Society, of Charleston
              Mr. Robert A. Johnson, ExOcutive Director, Appalachian Regional Health
              Policy and Planning Council, from Greenville






        SCRMP Site Visit Report               -2-
        Dr. H. Parker Jones, Representative of the Medical Districts Committee,
        a practicing physician, Charleston
        Dr. M. Tucker Laffitte, Jr., Chairman of the Cancer Committee, a prac-
        ticing physician, surgeon, from Columbia
        Mr. Henry M. Lee, Chairman, By-Laws and Nominations Committee of the
        Regional Advisory Group, Board Member of the S.C. Heart Assn, a
        Businessman of Greenville
        Miss Anne Liss, R.N  Member, Education Committee of the RAG, Registered
        Nurse, of  Columbia
        Dr. William C. Marett, Director, Div. of Chronic' Diseases of the State
        Board of Health, Columbia
        Mr. Roger H. McCants, Program Representative, SCRNP
        Dr. William Mellen McCord, President, Medical University of S.C., the
        Immediate Past Chairman of the Regional Advisory Group - 1966 to 1970
        Dr. William C. McLain, Jr., Associate Coordinator, Section on Continuing
        Education, SCRMP
        Mr. J. Albert McNab, President-Elect of the S.C. Hospital Association,
        and Administrator, Hampton General Hospital, Varnville, S.C.
        Mr. M. L. Mead'ors, Executive Director of the S.C. Medical Association
        and member of the Regional Advisory Group, Florence
        Mr. Marvin H. Miller, Executive Director of the S.C. Heart Association,
        from Columbia
        Dr. Vince Moseley - SCRMP Program Coordinator
        Mr. D. Kirk Oglesby, President, S.C. Hospital Association, Administrator,
                     rial Hospital, from Anderson, a member of the Regional
        Anderson Memo
        Advisory Group
        Dr. Kenneth Owens, Representative of the Medical Districts Committee
        and the Education Committee of Ithe RAG, a Practicing Physician, Aiken
        Dr. Loren F. Parmley, Director of Medical Education, Spartanburg General
        Hospital, Spartanburg
        Mr. Marvin J. Poliquin, Program Representative on the SCRMP Staff
        Mr. Timothy A.L. Pryane, Assistan t for Audiovisual Services and Educational
        Aids, of the Section on Continuing Education, SCRMP
        Mr. Gene Shaw, Administrator for Program Analysis on the SCRMP Staff
        Dr. Charles P. Summerall III, Associate Coordinator for Heart Disease
        and Stroke  SCRNP Staff
        Mr. Howard Surface, Program Representative, SCRMP Staff
        Mr. S.J. Ulner, Director, Office of Comprehensive Health Planning, State
        Board of Health, Columbia
        Dr. Blanche Urey, ConsRItant for Nursing and Allied Health Education, SCRMP
        8taff,@faculty member of the College of Nursing, Medical University of S.C.
        Dr. Keene Wallace, Acting Coordinator for Cancer and Nuclear Medicine,
        DCRMP Staff, Head of Dept. of Radiation Therapy, Medical University
        of S.C.
        Mr. William J. Ularlick, Executive Associate Coordinator, SCRMP Staff
        Dr. C. Tucker Weston, Chairman, Medical Districts Committee of the RAG,
        I-% Practicing Physician, Orthopedic Surgery, Columbia
        v@rsi Catherine Wheeler, member at large of the RAG, of Columbia









                SCRMP  Site Visit Report          -3-
               Mr. Norris Whitlock, Director for Epidemiological Studies, SCRMP Staff
               Dr4 Louis Wright, Jr., Vice-Chairman of the Regional Advisory Group,
                Practicing Physician, a Pathologist, the McLeod Infirmary, Florence,
                South Carolina
               Mr. Charles Wyrosdick, Director of Communications, SCRMP Staff
               Mr. William L. Yates, Executive Director of the S.C. Hospital Association,
                from Columbia, member of RAG
               Mr. Robert Yotmgerman, Inter-Regional Representative of the RMPS, Atlanta, Ga.






        BACKGROUND: The SCRNP is in its 03 operational year (8/l/70-6/30/70).
                     It was originally awarded $1,292,79i-(d. C.) of which $456,489
        was for Core support and $836,293 supported 16 projects.  As a
        result of recent cutbacks on all Regions, SCRNP's support for the
        curre@ year has been reduced to $1,162,109.  Adjusted budgets have
        not as yet been received by RNPS.

        For its 04 year the Region has submitted a Triennium Application
        that proposes:

             I.  A Developmental Component
             Ilo The Continuation of Core and Three Ongoing Activities
                 (#5A, #29, #31).
          III
                 The Activation  of 1 Council Approved but Unfunded Activity (#22)
             IV. The Renewal of 1 Activity (#13 R)
             V.  The Implementation of 20 New Iactivities (#39-#58)
            VI.  The Termination of 12 Activities

        The Region requests $2,991,048 (d.c.) for its-fourth year of operation,
        $2,727,436 (d.c.) for the fifth year and $2,993,955 (d.c.) for its
        sixth year.

        Staff conducted a prelimin
                                   ary review of the application and
        identified the following as issues which needed further clarification
        at the time of the site visit.

             1.  The functioning of the large 70-member RAG.
             2.  The effe t of the RAG's composition, with  the  prep
                         c                                          onderance
                 of Medical Society and hospital interests, on the  program
                 priorities and policies.
             3.  The effect of the various committees' composition  on program
                 priorities and policies.
             4.  The specific functions of Core Staff members and   their
                 relationships to the.community, Local Advisory Committees,
                 RAG and each other.
             5.  The program objectives,, the bases on which they were established,
                 the time frame for achievement and the method of evaluation.
             6.  Clarification of the review process.
             7.  The evaluation processes, both project and program.






                                                 -5-



                                   ;ite Visit Report Of The
                         South Carolina Regional Medical Program
                                    March 16-17, 1971


                AGENDA: By prior agreement the site visitors and SCRNP representatives
                        met in plenary session the  morning  of  the  first  day,  then
                split into three groups based on  the  Region's  major  program  sections:
              ;1) Heart Disease, Stroke and Related Diseases, 2) Cancer and 3) Continuing
                Education.  A plenary session was held the morning    of   the   second
                day followed by a feedback ses  sion with the Region  and  an   Executive
                Session.
                OVERALL OBSERVATION: It was the  feeling  of  the  site  visitors  that
                                      this Region, while it has not demonstrated
                outstanding maturity  or  quality,  has  made  substantial  progress
                during its first  three  years  of  operation.  Given  the  limitations
                of,categorical diseases and traditional continuing education activities
                under which the  first  thkee-year  operational  plan  was  designed
                .Ind initiated, the  Region  appears  to  have-established  a  program,
                within its.broadly stated objectives, focusing on some of the
                major problems  of  South  Carolina.  It  has  concentrated  through
                continuing education activities to upgrade the knowledge of the
                rural physicians who in most  instances  have  not  kept  current  with
                modern medical procedures related to heart, cancer and stroke
                and who are treating  a  large  number  of  disadvantaged  patients.
                A number of the training programs have been conducted through
                State-Aid Heart and Cancer Clinics which have not only     Iserved    to
                upgrade th e procedures in  these  clinics  but  have  also  improved
                relationships  between  clinic  physicians  and  the  local  practicing
                physicians who are  now  making  increasing  referrals  to  the  clinics.
                Since the initiation of  the  CCU  training  projects  it  three  rural
                hospitals, twenty-gix other small  hospitals  have  seen  fit  to  develop
                CCUS. Through  stroke  and  cancer  projects  SCRMP  has  succeeded  in
                improving facilities and  services  in  communities  of  which  most  are
                medically deprived areas.  In addition the Tri-County Cervical Cancer
                Screening Project has served  to  increase  the  number  of  routine  pap
                smears being  taken  by  private  physicians.  While  there  have  been
                varying degrees of  effectiveness  among  the  projects  supported  during
                the first three years  of  operation,  the  Region  has  been  successful
                in establishing credibility and cooperation with the more
                conservative elements of the medical community and the Medical University.
                the site visitor                  --Pe ion's             his sphere mor  e
                                 a felt thattliii    9      success  in  t
                than  compensates  for  individual  project  deficiencies.
                GOALS, OBJECTIVES &  PRIORITIES:  The  program  goals  and   objectives
                                                    established  for  the  new  triennium
                remain  basically  unchanged  from  previous  years.  The  visitors  were
                disappointed to find  that  the  foregoing  are  highly  categorical  and
                are  implemented  primarily  through  traditional  continuing   education
                activities. Furth&r, the  goals  and  objectives  fail.  to  reflect  the
                broadening philosophies of Regional Medical Prograffi Service.  However,
                the visitors noted that the Region seems to be one that plays according





                                           -6-


         to the book, and probably this    triennium  application  was  being  drawn
         together at the time when RNF wasstill basically limited to categorical
         and  continuing  education   adtivities.'.

         The visitors also  considered  the  fact  that.given  the  reluttance  with
         which the medical commuiiity-has accepted SCMT, it will not be rushed
         into accepting new and perhaps "revolutionary" philosophies.  In view.
         of this the  visitors  still  felt  the  overwhelming  problems  of'South
         Carolina imposed a special responsibility on SCRMP to reconsider
         its objectives and to make  a  concentrated  effort  in  the  future  to
         redirect the program toward activities which will 'more directly influence
         patient tare.
         The goals, objectives and   priorities  do   not seem to be based on
         a careful assessment  of  -regional  'needs, but rather  randomly   selected
         by convenience  and  only  secondarily  sqgt  to fit into a pattern.
         However, problems and resources  do  appear  to  be  taken  into  account
         with some  regularity  and  there  has  been an attempt to make them congruent
         with'udtional priorities.  The      Region's reasoning  for  not  setting
         more  specific,objectives  was'that  in   so doing it would limit its
         flexibility to initiate some important activities.       Nevertheless,
         the visitors  believed,  in  order  to  give the.program .certain direction,,
                                       e               ed in  more  specific  and
        -there is a need for o'bjectiv s to be defiri
                                                               COMP
         measurable terms and set in a time frame  for     ac     lishment.
         While the goals   and objectives  appear  to  be  publicized  throughout
         the Region primarily by RAG members      and @hei SCRMII newsletter,  the
         visitors had some doubt that many of     the people  involved  in  SCRMP
         truly know Pr understand   them.     Howeveri with the development of
         the L              t Committees such communication is 6xpected-to improve.
               ocal Distric
         ORGANIZATFONAL EFFECTIVENESS: Dr. Moseley, the     Program Coordinator, is
                                          a personable  and fairly effective individual.
         He has apparently served,, ar6ng wit"h Dr.@ Summerall, who onte served
         as Coordinator, and  Dr.  McCord  the  past  RAG Chairman,  as  the  force
         drawing  together  the  various   factions of   the medical  community,   some
         of  which  were  not  initially  receptive to SCRMP.  Dr. Moseley is highly
         respected by  both  members  of  the  RAG, his staff,  and  a  parently  by
                                                                    p
         the  medical  community  as  a  whole.  He appears  to  be  providing  the
         moderate leadership necessary to change attitudes in the South Carolina
         medical community  without  alienating  some  of  its  more  conservative
         elements. While  feeling  he  has  been  a definite asset to .the program,
         the visitors believed there is a need for him to provide T'ore clearly
         defined direction to the  program  and  to  broaden  its  scope  through
         direction away  from  categorical  and  continuing  education  emphasis,,
         toward solving some of the more pressing problems of South Carolina
           high  infant  mortality,  malnutrition,  patient  access  to  services,
        lack of motivation of uneducated to seek services).






                                              -7-



             The University or grantee organization does appear to provide adequate
             support and freedom from a strong policy-making role.

             The RAG appears to have participation of most of the  key  regional
             groups and interests, however, it also has  apparent  weaknesses.  The
             concern expressed prior to the visit, that the large  70-member  RAG
             might be unwieldy, in itself did not appear to the visitors  to  be
             a serious problem, although some RAG members felt it should  not
             be expanded further.  The visitors' major concern was that the 24-member
             contingency of M.D.s representing the 10 Medical Districts of  the  State
             along with the 21 other physician representatives provides  an  imbalance
             highly in favor of the M.Ds and the Medical Society,  which  other
             members of the RAG find unfair and discouraging to  work  with.  In
             private conversations certain members stated that some M@.Di  members
             only attend those meetings at which critical issues are  voted  on
             and then only at the urging of other M.D.s lobbying for  certain
             issues or projects. A recent amendment to  the  by-laws,  which  imits
             consecutive absences to two, has been adopted in hopes  of  curtailing
             such practices. The visitors were not,sure that  this  by-law  might
             not also serve to disqualify some of the minority group  members  who
             find it a financial burden, in time lost from jobs,  to  consistently
             attend meetings.

             Aside from two nurses representing the State Nurses  As'sociation,
             there is no other allied health representation on the RAG. The
             Region states that the allied health representatives will  serve
             on the Medical District Committees and allied health input  will
             therefore be through District Committee representatives to  the  RAG.
             The visitors thought this inadequate in that the  Region's  by-laws
             limit District Committee membership on the RAG to  physicians,  and
             thus allied health representation will always be indirect.  The visitors
             speculated that an alternative to this problem might be to  have  each
             District Committee represented on the RAG by one physician  and  one
             member of an allied health profession.

             Although there are nine Black representatives on the RAG,  two  of
             whom were present for the site visit And appeared  very  defensive
             of the program, the degree of their involvement remained unclear.  The
             Absence of a member of the Palmetto Medical, Dental,  and  Pharmaceutical
             Society ( a Black,organization) on the RAG , as called for by the by-laws,
             was defended by the Coordinator who explained  numerous  invitations
             to participate have been made, however, there has  been  no  response.
             The visitors also questioned the viability of the  Palmetto  organization
             since there was some indication that it has declined since Black physicians
             began to be accepted into the South Carolina  Medical  Association.
             Aowevet, the team noted that SCRMP did not appear to be very knowledgeable
             about the Organization and that further investigation  and  attempts
             at cooperation would be in order.

             The RAG appears to have some, but not strongi policy  control  over
             the program. Rather it relies heavily on  the  Steering  Committee
             and the Categorical Committees for direction. These  committees  in  turn
             appear highly influenced by the Associate Coordinators on Core Staff;





                                               -8-



                          all   M.D.,,   Heart   Stroke,   Keene    Wallace, M.D.,
           Charles Summer-
           Ca   cer,and  William  McLain,   M.D.,   Conti   ing   Education. In   fact   it
            n                                           nu
           appears these  three   individuals   along   with   the   Coordinator   provide
           the  direction  of  the  program.
           The visitors Aere pdrticularly@impressed with the philosophy of
                                                                           t   of   Academic
           Vale new RAG  Chairman.,  J.W.   Colbert,   iA.D.,   Vice-Presiden
           Affairs At  the  Medical  University.  It   appeared   from   his   few   brief
           statements  that  he  envisions  a  change.in   direction   for   the   Region.
           He placed priority on a clearer identification:of needs and concentrated
           .fort  on  specific   health   problems   among   certain   identified   population
           plr.oups, in  the   Region. He   indicated   new   and   imaginative   approaches
               be undertalren-and.they must relate mote         directly  to  the   population-
           oeing  served.  The-visitors  felt  Dr.  Colbert   has   much   to   offer   SC@T
           at a time -when it needs to broaden its sdope.. Whether he will be
           successful  in  having  SCRT-4P  accept  his  philosophy  is  que stionable
           and  should  prove   interesting.


           SUBREGIO.NA:i,IZATION:  Tho-.site     visitors were  for  the   most part     favorably
                                      ress6d  with  the  Region's   efforts   to   promote
                                   imp
                                                                           te    Coordinator
           subregionalization.     Under   the direction   of   an   Associa
           fo               istri s   Program   Planning- $CF-NP   has    established-local
            r Medical D         ct
           advisory    committees in  the  ten CHP   Medical   Districts   designated    by
           th                 While        ommittees  will  be   involved   in   assessing
            e Governor.            these   c
           needs  and   identifying   activity    priority areas,@they are onl
                                                                                 y  now
                  ng                                            ave   such input.  Each
           ecomi   'functional    to  the   degree   that the     h
           b
           Committee  is-irepre,ented   on-the'PAG    by a:minim@im   of   @wo   physicians
           appointed by  t!ae  South   Carolina   Medical Association,   a fact  which,
           as  cited  before  results  in  physician   and.Medical    Society     imbalance
           on  the  RAG.  Along  the  same   lines,   the visitors   believed    the    selection
                         'ttee mdmb
           of  other comrm           ers   b                        sici   s    further
                                           y these appointed phy         an
           compounded  the physician-Medipql   Society   influence   on    the    Program.
           The visitors were pleased to'learti that the       two-CHP   (B)   Agencies   and
           the   Appalachia   Agenc shard   committee   representatives   with   the
                                  .y
           respective   Di-strict   Committees...However,   given,the   newness   of   District
                                         s              '(B)  Agencies  nothing   of
           Committees and the weaknes      of   the   CHP
           significance  has   as yet resulted.
           iNVOLVEMEiiT OF REGIONAL RESOURCES: With few exceptions all of the Region's
                                                   major   resources,   sparce   as   they
           are,  are  rep-resented  on  the  RAG  and  appear  to be  actively   involved   and
           committed.  7.h;a large heart and cancer components make it understandable
           that the South Carolina Heart Association and        the American     Cancer
           Association   have   special  interests   and   particular   enthusiasm   for
           the                                          al  Association  with  its   large
              ,prog-ka.m.  The   South   Carolina   Medic
           contingency on the RAG, Steering Committee,        Categorical    committees    and
           disttict'committeds obviously dominates the        program.   Uhile   the    Medical
           T,'niversity's representation on'the RAG is relatively small, its
                                                                            and     Cancer
           .Lnfluence -i-s exerted more indirectly throu-Ii the        Heart
           .,Iz-sociate Coordinators who serve   part-time   as  Core  O@taff,  but   u@ro are,







                                             -9-



              in fact, faculty members at the University. The  University  representatives
              appear very closely associated with the Medical Society  and  respective
              of its philosophies and supportive of its interests.
              Involvement of the two CHP (B) agencies, the two Model  Cities  agencies
              and the Appalachia Program is indirect in that these organizations
              do not have voting representation on the RAG but ate represented on
              the Medical Districts Committees. This arrangement  the  visitors
              felt to be questionable, in that, given the power structure as  established,
              any impact form these agencies would be from remote positions  In this
              regard particular concern was expressed over what appeared to  be
              minimal involvement of, and coordination with, the Appalachia Program
              which is extremely active, and has in two years time provided some
              11 million dollars of health-related grant support to  Medical  District
              I.

              While the nursing profession is represented by two members of the
              State Nurses Association, it is difficult to imagine that these
              individuals have much impact given the overall size of the RAG.
              It was the visitors' belief that in view of the Region's interest in
              using developmental funds to determine the feasibility of a physicians-
              assistant pro.gram, which might take the form of nurse-practiti6nets;
              the involvement of more nurses might be seriously considered.

              Allied Health Professions representation have been nonexistent in
              the program, a situation which the Region proposes to rectify  by
              the inclusion of such individuals on the Medical District Committees.
              However, the sit,= visitors felt that, as with Appalachia, Model  Cities
              and CliP. the impact at this level would be lgst within the power
              structure. They believed that given the importance of the allied
              health professions their impact should be more direct.
              ASSESSMENT OF NEED: Like most other Regions, SCWV's assessment of
                                  needs is not systematic and admittedly its data-
              base is inadequate.  Program objectives and projects have been developed
              subjectively on what are considered apparent needs rather than on
              objectively assessed needs, a method which seems to have worked surprisingly
              well during the first three years of operation. In view  of  the  recognized
              absence of resources providing data information, the Region is proposing,
              through the use of developmental funds, to study the need and organizational
              plan force development of a  Department of Community Health Services
              at the Medical University.  Oae of the many functions of such a
              department would be to maintain pertinent health care data  and  provide
              this in suitable form to the various dare and service agencies.

              PROGRAM IMPLEMENTATION AND ACCOMPLISHMENTS: Core Staff appears competent
                                                          and its activities have
              resulted in some action-oriented planning and the development  of  community
              organization at the local level.  The three Associate Coordinators, have
              been, to date, the ptitw movers within their respective sections of the
              program; Heart, Cancer and Continuing Education,  They have had significant
              influence in determining needs, setting and direction of the three






           progKams and on the types of proposals generated.  Given the responsibilities
           these individuals have assumed in the past, it  will  be  interesting
           to see how their roles will be altered once the Medical District
           Committees become more functional in  assessing  local  needs  and
           developing ideas for proposals.
           The two Subregional Assistants appear less  directly  involved  in
           promoting projects and play more significant  roles  in  maintaining
           liaison between SCRMP and the subregional  areas.  They  serve  to
           coordinate and promote between health providers, cooperative activities
           some of which are supported by SCRNP and others not.
           Project surveillance is carries out through the  Director  of  Program
           Liaison and Planning and Evaluation and his staff  of  four  Program
           Representatives. While project surveillance  and  evaluation  in  the
           past has.been admittedly weak, due to the  original  projects  not
           having built-in measurable objectives, steps have  been  taken  whereby
           the project Idirectors, with the assistance of  the  Liaison,  Planning
           and Evaluation Staff, now include evaluation mechanisms in each Project
           as it is being drafted.  The project director and  staff  will  then
           evaluate quarterly the achievements of the  individual  projects  and
           annual evaluations will be submitted to the RAG.
           Program evaluation, like,prqject evaluation, suffers from non-specific,
           immeasurable program objectives.  However,  unlike  project  evaluation
           no Attempts have been made to identify objectives in  terms  which  can
           be monitored. The absence  of  specifically  stated  objectives,  not
           only creates a toblem f6r Staff in  evaluation  but  also  provi es poor
                          p
                      for Staff involved in  promoting  related  activities  and..
           confusion for potential project sponsors.
           OPERATIONAL PROJECTS: The visitors felt that  while  the  projects
                                  conducted during the first three  years  were
           of less than high quality and only  moderately  productive,-they  had
           had significant impact on health in the State  and  demonstrated  an
           ability to promote interest within the  ten  subregions.  They  also
           served to provide linkages between institutions,  the  most  significant
           being between the Medical University and  outlying  hospitals,  clinics
           and physicians, thorugh these projects much of  the  skepticism  many
           of the South Carolina physicians harbored about SCRNP has been removed
           and the confidence of the various health interests  of  the  medical
           community has been won.
           The projects which represent the program for the  next  three  years
           are basically the same quality and designed along the  same  lines  as
           those of the first three years, categorical  and  continuing  education,
           and they relate to the overall objectives in  the  same  manner.
           The visitors had difficulty understanding the 1).igh priority given some
           projects.  They did not feel, one project in particular, #51- A Program
           for Continuing Education for Health Professional.s and Allied Health Personnel
           (which is a T.V. production and broadcast type activity  on  the  campus            '@"/,
           @of the University), could justify its high-priority ranking when considered






              against the grave health needs of the Region.  While the visitors
              recognized Regions now have responsibility for the  technical  review
              and priority-setting of their projects, they  believed  SC@  should
              be made aware of these concerns and encouraged to reconsider the
              value of this pro4ect in view of South Carolina's more serious  needs.
                              i
              The visitors believed Project #52 - Health Manpower to be  in  direct
              conflict with current MOS policy, which states that RMP  funds  are
              not to be used for direct operational grant support of Health  Careers
              Recruitment projects.
              DEVELOPMENTAL COMPONENT:  The Coordinator identified the  same  ideas
                                        for use of developmental funds as are
              outlined in the application, which were: to study the needs and
              organizational plan for a Department of Community Health.Sciences
              at the Medical University, to conduct studies with applicant hospitals
              as to ways by which the strengthening of community hospitals can
              be achieved through regional planning for services, and to  conduct
              studies as to the regional needs in respect to specific aids  in  the
              promotion of health care and services, such as: 1) Physicians Assistant
              Training Programs, 2) Improved Patient Chart and Record Methods, 3) Computerized
              Patient Records, 4) Health Services Directories.
              The visitors were-satisfied that the proposals for use of developmental
              funds are sound and will serve to advance the SCRMP and health care in
              the Region. Although some concern was  expressed  that  developmental
              funds would be used in the actual establishment of the  Department  of
              Community Health Sciences, Dr. Mosely Assured the visitors  this  was
              not the case and such funds would be used only for study and planning
              purposes.
              READINESS FOR DECENTRALIZED REVI!EW PROCESS: In terms of the  proposed
                                                          requirements or standards
              that a Region's review process must meet before project review authority
              will be decentralized to it, South Carolina seems to  have  organized
              a generally well-balanced and comprehensive review process.  It
              generally includes provision for determining (1) the technical
              adequacy of.proposdd operational projects and (2) which proposed
              activities are to be funded within the total  amount  made  available
              to the Region.
              Review Criteria and Program Priorities - The Region  has  developed
              what it calls a "Priority Appraisal Ch6cklist," which  reflects  both
              national and regional objectives  It includes a section on background
              (e.g., extent of current deficiency, existing  resources);  objectives
              (e.g., nature of target population, extent to  which  it-will  affect
              efficiency and accessibility); implementation and methods such
              as degree of regionalization involved; and finally potential effectiveness
              and continuation, which tries to measure plans for evaluation) prospects
              for continuing support, etc.
              Staff Assistance, Review and Surveillance -  There seems to be a good deal
              of staff assistance in developing projects and moving them through the




                                       -12-




            review process, although it was felt that the core staff could  play
            mIore of an advocate role in developing projects to meet overall
            RMP priorities, as opposed to providing assistance to those  projects
            being developed by institutions in the Region. In terms  of  surveillance,
            a quarterly project progress report has been attempted in the  past,
            b,ut.the core staff admitted,there was a need for stronger surveillance
            and a greater effort to get an evaluation component ir@to the project at
            the very beginning, so that progress could be continually  measured.
            CliP Review and Comment - South Carolina seems to be one of the first
            "regions to have complied with the new policy statement requiring CHP
            review of MV applications. Appropriate portions  of  the  application
            were sent to both the State CHP agency and some 5 Areawide CHP  or
            regional development agencies for comment. There seems to be  a  good
            relationship between the RMP Local District Committees and the
            CHP Health Planning Councils, with shared REP-CHP membership on  the
            committees which have been established in most of the 10  districts.
               re iqnal and Technical Review Structure - There  are  essentially
            three levels of review before projects reach the Executive  Committee
            and the RAG. These are the 10 SCRMP Medical  District  Committees,
            which review and promote projects in terms of overall local  needs
            and priorities, the four technical review committees namely,the
            Heart and Stroke Committee, Cancer Committee, Related  Disease  Committee,
            and the Education Committee, dhich review the projects in terms  o
            both technical merit and committee priorities, and the core  staff  review.
            Both the technical review committees and the core staff review  make
            use of the "Priority Appraisal Checklist," as well as  specific  committee
            priorities so that all projects are ranked for any given round of review.
            RAG Ranking and Funding Determinations - The South Carolina RMP  has
            established a process whereby committee and staff reviews are
            coordinated into a final I(AG list of project priorities.  The Executive
            Committee receives the reports and recommendations of (1) the  medical
            district committees, (2) the technical review committees, and (3)  the
            core staff. The Committee attempts to coordinate the  rankings  of
            the three groups, creating a mix of projects that provide program balance,
            followed by presentation to the RAg for discussion and decision.
            Feedback and Appeal Procedure - Although a technical review  committee  or
            the Executive Committee can give a project a low priority, only  the
            Regional Advisory Group tan disapprove a project and as such is  the
            final arbiter. The opportunity is provided for an  applicant  to  discuss,
            the proposal at a number of points along the review process, including
            the technical committees, core staff, or the Executive  Committee.  if
            a low priority is given by these committees, the applicant can  appeal
            to the RAG. Feedback includes either reasons for  receiving  low  priority
            considerations, or changes that should be made in the project to  make
            it more consistent with overall regional objectives and  priorities.
                                                                                        I    , @,






                                              -13-



               FEEDBACK TO REGION: At the conclusion'of the visit, the chairman of
                                    the team met with Dr. Mosely  and  other  SCRNP
               representatives and identified the following aspects of the program
               as areas of needed strength:
                      1.  The program remains basically categorical and educational
               in nature, thereby disqualifying some of the more serious disease problems
               of the Region and limiting the types of imaginative projects generated
               for their solution.
                      2.  The composition of the RAG is unbalanced and heavily in
               favor of the M.D.s and  Medical  Society  interests.  Also  there,is
               under-r4ipresentation of allied health interests  and  the  Palmetto
               Medical Society.
                      3.  While the Region's overall goals and objectives are mote
               specific than most, there is a need for them to be identified in more
               specific and measurable terms or to establish more specific sub-objectives.
               Also, they should be more closely related to "assessed needs
                      4.  Core Staff has functioned to date as a catalyst to persons
               who have had projects they wished to have funded, not as a stimu ator
               of projects designed to meet specific objectives.
                      5.  While the SCRNP has taken positive steps to improve project
               evaluation, program evaluation needs additional strengthening beginning
               with measurable objectives.
                      6.  Although rapport has been established with OEO, Model Cities,
               and  Appalachia  Agencies,  there is a need for closer working relationships
               and coordinated planning.
               RECOMMNDATIONS:  The visitors concluded the South Carolina RMP is
                                  ready for triennium review and developmental    support.
               The  following  support is recommended for each of three years.
                      1.  Approval  of Core   at,     $500,000
                      2.  Approval  of project
                          support  at:              $1,@27,04i
                      3.  Approval  of develop-
                          mental  componeiit'at:      .$looooo
                                                    $1,727,041
               Project  #52 - Realth,Manpower   is in direct conflict with current RMPS
               policy and inappropriate for RMPS support.
                                                                           GRB/KTS
                                                                            4/19/71










                                           OUSQIjT,@H@,NNA VALLEY


                                                 Summary


                                            Table of Contents



              Introduction. and List of Issues                                     P.
                                                                                   p.  2
              ,ti,iiiding History
              Geography and Demography                                             p.  2
              Regional Developpjent                                                p.  2
              Regional Objectives                                                  p.  4
              organizational Structure and Processes                               p.  4
              Present Application                                                  p.  5
              organizational Chart                                                 p.  12
              Staff Revie@g of Nori-Coripeting Continuation Applicat4orL           p.  13
              Correspondence Regarding I-,TithdraT,.7al of Project #26             p.  16
              Project Component Analysis                                           P.  17
              Budget Breakouts                                                     P.  18
              Summary of Previous Revic,:@q by Committee and Council               p.  23








                                                      RAMS SERVICE
                                    IONAL MEDICAL PROG
                                 OF ANNIVERSARY REVIEW AND AWARD APPLICATION
                                      (A Privileged Co @ aication)
            SUSQ      A VALLLFY REGIONAL KEDICAL PROGRAM    Pk 00059 2/71.1 (AR-lWCDS)
            3806 Xarket Street, P. 0. Box 541               January 1971 Review  C-oftittee,
            Oavp  Hill, Pennsylvania   17011                Revised for April 1971
                                                             Review Committee

            Prggrm   Coordinator:   Richard B. McKenzie
            ,This Region is curtently.funded at $671,997..(direct costs) for its thard
            operational year  ending  March 31, 1971.  Indirect costs amouAted to
            $154,402 or 22.9% of direct costs.  The Region 'Submit$ An Anniversary
                                          es the following:
            Roviuw  Application  that  propos

                  1.  A Dievelopmental Component
                  2.  The continuation of core and three ongoing projects
                  3.  The activation of four Council approved but unfunded Activities
                  4.  The renewal of one activity
                  5.  The implementation of seven new activities
                  6.  The termination of six activities
            The Region requests $2,.111,189 for its third year of operation, $1,660,035
            for  its fourth year of operation, $1,575,425 for its fifth year of operation..
            A breakout chart identifying the components for each of the three vO4t$
            can be found at the end of the@sumnary.
            A site visit is planned for this Region, and st4ff's preliminary review
            of the.application'has identified several issues for the site  visit team'S
            consideration:'
                  t.- I!he 'i:h@i'in the r-eg@onal decis'ion-making proe6s6-,4hi@la'@a've@
                      led to'.i'ihift in program emphasis, f:eom.primarily A coronary 4are,
                      centered program to a more comp    ri
                                                     rehe sivt one.
                  2.  J*ogresg in determining goals and objectives and in setting
                      priorities..
                  3i  Pkogress in developing regional planning capabilities, both on
                      core staff and at the task force and RAG level, as contrasted with
                      to present practices in planning on a community  by  Country  basis.
                  4.  the degree of control maintained on the program by the,.Pannoylvani4
                      Medical Society, which serves As grantee agency.
                  5.  changes in the relationship with th@'Hershey Medical School.
                  6.  improvement in the relationship between core staff and the  Regional
                      Advisory Group.
                  7.  the extent to which the Region has utilized consultants in technical
                      And specialty areas from within and outside the Region to supplement
                      the effor
                               ts of the completely lay staff.




              SUSQUEHANNA    VALLEY    RNP              -2-                    RM   00059   2/71.1 (AR-1

                    8.    the    viability of,the newly revised review process.

              These issues    are   discussed   in further  detail  in  the   summary,   the attached
                                              e@  January 1971  c'ritJ.'que  of  the  applic  tion for
              staff  memo  and   in   Comm tte   s                                           a
              Council   (blue   sheet).,-.

                                                  FUNDING HISTORY


                                                  Planninc., Stage

              Grant    Year                          Period                         Funding  (d. r-'. OL-i

                   01                        6/l/07-5/31/68                        $253,530:
                   02                        6/l/68-3/31/69                         250    056

                                               Operational    Program
                                                                                                 Future
              Grant    Year    Period               'Council  approved        Funded d.c.o.     Commitment

              01          4/l/69-3/31/70                  $698,052               $5.32,444 1/
              02          4/l/70-3/31/71                 666,495                   611,997 2/
              03          4/l/71-3/31/72                 695,333'                                545,915
              04          4/l/72-3/31/73                 65OJPO75                                497,644
              -@05        4-/I/73-3/31/74                483,294

              1/.--Represents   75%@.funding    of projects

              2/   Includes $124,390     in carryover
              Geography       and,Demog@aphy

              This Region consists of 27 counties in the central corridor            of    Penns ylvania
              bordering on Karyl,and in the south..and New York in the north and separated
              from  the  W6stern  Pennsylvania  and  Greater  Delaware   Valley   RMPs   by   moun-
              tainous terrain.  The total population o.f.the Region          is   projected   to be
              2,323,751 (1970 Census).  Much of this population is           centered     around the
              three  urban  areas,.but  the  Region   also   contains   large@rural   and   forest
              areas    with low   population   concentrations   and    underdeveloped    facilities.
              The    Milton S. Hershey Medical Center of the Pennsylvania State          University
              was established in 1963.  The first class was enrolled-in 1967; the
              present enrollment is 147.  The Region also has.55 hospitals'.             It is-served
              by  1,776  M.D.'s  and   218 D.O.'s.  There are 8,909.active         nurses.

              Regional  Development

              In 1966  the Susqiiehanna Valley Committee       on  Heart  Disease,   Cancer   and
              Stroke,  presided over by the President of the PennsylvaniL Medicai- Society
             ,(PM&), met to plan an-RMP for.the central         Pennsylvania Reg.-Lon.  The first
              planning  grant,   submitted    by the PNS, was   approved  in  June  1967  bond:Lftg
              clarification  of  the   role   of the new medical school, the state
              department   and   administrative.and.staffing    patterns,    and.assu    @.r@e






           SUSQUEHANNA VALLEY RMP            -3-                  RM 00059 2/71.1 (AR-1@CSD)

           allied health involvement. The Executive Director,of the  PMS,  Mr.  MhKeazie,
           was appointed Coordinator in August 1967.

           During the second planning year, the Region encountered a number  of  problems
           with the completely lay Core staff and the grantee agency, which considered
           the RMP Core staff as another branch of the FM . There  was  strong  senti-
           ment among Core staff regarding the degree of control the  PNS  maintained
           over routine office matters and the relatively low  salary  scale.  Several
           staff members resigned as a result. There was also  some  confusion  about
           the relationship between the RAG and the PNS Board.  A  management  consulting
           firm was retained to study the entire program and recommended certain
           staffing changes, some of which have gone into effect.

           The Region began work on its initial operational application  which  would
           contain five coronary care unit proposals and a request to  train  coronary
           care unit nurses. A site visit was held in  Detember  1968.  The  visitors
           recommended operational status to convince the local physicians  that  RMP
           would actually help them improve patient care. While  leadership  from  the
           RAG was slow in developing, the Region had an impressive amount  of  physician
           involvement at the grass roots level through the Area  Committee  structure.
           In fact the bywords for the SVRMI? in these early days became  "grass  roots
           involvement and "coronary care." Council  approved  the  Region's  request
           with the understanding that the CCU projects were pilot projects  for  the
           Region with evaluation of the results before additional projects ate funded
           and with the stipulation that 50 percent of the equipment funds be made
           available for physician training. Shortly afterwards  three  more  proposals
           were submitted, approved and funded. They were a stroke care  unit,  a  home
           health pare project and a regional medical information service.

           New projects submitted during the second year, however, continued to
           emphasize coronary care.  Reviewers found them, on the whole, to be-a
           disparate group of projects, attacking the problems of coronary care in
           an isolated fashion. They disapproved the projects  and  recommended  that
           the Region establish an overall plan involving greater  coordination,  coop-
           eration and consolidation. Core and the coronary  care  training  proposal
           at the Geisinger Medical Center were renewed.

           A site visit held in February 1970 reviewed the overall progress of the
           Region and four new projects.  They concluded that the Region should:
           1)  consider broadening the base of its grantee agency to  insure  that,all
               appropriate groups feel represented.  A change to a nonprofit corporation
               was seen as a possible solution;

           2)  utilize consultants from both inside and outside the Region  to  improve
               efforts in data gathering and epidemiology;

           3)  appoint a liaison member of the Hershey Medical School  faculty  part-time
               to the RM11 staff to both improve relations with the new medical  school
               and involve physicians on Core staff;

           4)  while continuing to encourage grass roots involvement, devote more
               attention to developing a regional decision-making process which,






                                                                           (AR-1-CSD)
            SUSQUEHANNA VALLEY RMP        -4-              RM 00059 2/71.1
              selects projects on the basis of a regional plan@ rather than just on
              a community's needs.
            Projects funded during this past year include:
            1) an extension of the original five CCU's with carryover funds for an
               additional year,
            2) the CCU nurse training project,
            3) the second year of the SVRMP library information service,
            4) project #7, the Stroke Care Unit and #8, the Home Health Service,
               out of carryover, and
            5) projects #16, the Radiological Health Training Program and #17,  Columbia-
               Montour Home Health Services.  Projects #18, a Rheumatic Fever Control
               Program, and #19, a CPR project were approved but unfunded
            The Region submitted one further application during its second operational
            year.  Only the Enterostomal Training Program and the CPR and CVA Transport
            Vehicle, York, were approved.  Council requested additional information on
            the CCU Nurse Training Program at the Altoona Hospital before it could be
            approved (this information has been received and will be forwarded to the
            February 1971 Council).  The remaining four projects, including an   emphysema
            program, a stroke rehabilitation and training program, a cartridge viewing
            system pilot project and a supervisory CCU nurse traintng program'. were turnA,4
            dawn.
            The Region's present level of funding for its second operational year

            Regional Objectives
            The SWW frankly admits that its centralized program planning to date re-
            presents a disconcerted effort and that the Region does not have a specific
            plan which details specific objectives that result in specific  applications.
            Interest  in the past hashappened to center on heart disease and coronary units.
            At its fall 1970 meeting, the RAG established formal goals which set the stage
            for development of primary goals and specific objectives.
            The primary goal is to "improve the quality of patient care working with  and
            through the providers of health care as they function in the existing  health
            care system; and by influencing the present arrangements for health  services
            and by concentrating maximum effort on those activities which have the
            highest local, regional and national priorities."
            The primary goal is approached through specific goals in three basis  areas--
            organization, strategy and program.

            Organizational Structure and Processes
            The SVRMP has organized a 30-member RAG, with representatives from each of
            the four Areas and from various health organizations and institutions of
            the Region.  The RAG has Executive, By-Laws and Nominating Cormnitt ees and






               SUSQUEHANNA VALLEY RMP            - 5 -           RiM 00059 2/71.1 (AR-  CSD)


               is in the process of selecting Planning and Evaluation Committees        The
               RMP has divided the Region into four Areas, each of  which  is  served  by  a
               Committee ranging from 60 to  135  members.  Each  Committee  hag  appointed
               subcommittees to serve as study  groups  and  an  Executive  Committee.  To
               provide review and planning at the  regional  level  in  specific  functions,
               Councils (formerly Task Forces) have  been  established  in  the  categorical
               areas, as well as in Facilities and Services  and  Continuing  E  ucation..
               Each Council also sets goals and  objectives  in  its  respettive  interest.

               The review procedure consists of the following steps:
               1.   Consideration by the volunteer Area  Committees  through  their  Executive
                    Committee and spetialized subcommittees.

               2.   Consideration by the members of categorical councils who supply spec-
                    ialized professional technical review on a regional scale.

               3.   Consideration of the relevance  of the proposal to regional goals and
                    objectives by the RAG.

               At  each step, staff  members  provide  administrative  assistance.  Formal
               review procedures, including a set of  criteria  and  a  numerical  ranking
               system, which assigns all new projects a priority number, have been devised
               for the RAG.  Plans are underway to develop a similar system for the
               Councils and Area Committees.


               PRESENT APPLICATION:

               Developmental Component                                             $54,596

               Activities initiated through  developmental  component  funding  "will  seek
               to improve the quality of patient care by  working  with  and  through  the
               providers of health care as they function in  the  existing  health  care  sys-
               tem, by influencing the present arrangements  for  health  tare  services,  and
               by concentrating maximum effort on these  activities  which  have  the  highest
               local, regional and national priorities."  An  example  might  be  an  explora-
               tion of appropriate methods and means  for  developing  improved  patient  care
               techniques and systems in kidney disease prevention and control.

               The review mechanism described under organizational structure and processes
               above will apply to the developmental component as well.

                        $549596                                   $54,596

               Continuation Component

               These components have been reviewed  by  staff.  Their  program  and  funding
               recommendations are in a supplementary memo.




               SUSQUEHANNA VALLEY RMP            6              RM 00059 2/71.1  (AR-1 cst))

                                                                             $469o7Oo
               Core
               The SVRMP Core staff is completely lay.  Its Coordinator was the former
               Executive Director of the Pennsylvania Medicai Society, which serves as
               the grantee agency.  An organizational chart for Core staff is attached  to
               the summary.  The functions can be briefly defined as follows:
               1.  Technical  ervices - plans, establishes and directs the technical ser-
                  vices for:  Applications development, grants management, research And
               evaluation services, development and operation of library activities and
               general office management.
               2.  Co  nications - directs the production of communications material
                  and provides liaison with the news media.
               3.  Program Deve   ent - provides staff services to committees, councils
                  n@d planning groups, coordinates educational activities And programs,
               assists with the establishment of regional goals, objectives and priorities,
               and provides personnel recruitment services for staffing.  In addition,
               Field Services are included in this branch,  A field representative is
               assigned to each of the four Areas to provide regional coordination and
               staff services to all volunteer committees and groups in the Region.
               With the assistance of the field representatives, various Area Committees
               or subcommittees have developed standards,for coronary care  sponsored  a
               cancer detection clinic survey and conducted a cancer incidence And mor-
               tality survey.
               The SVRMP Core budget last year included funds for "program related acti-
               vities."  These are funds in the magnitude of $50,000, which the Region
               used for various purposes, such as to conduct pilot studies of various
               proposed project activities, hold conferences, and supply educational mater-
               ials to health professionals.  Types of activities for which these funds
               will be used next year Include a conference for regional directors of
               coronary care units, an audio-tape cassette scientific program service,
               data collection and a consultation program for tumor clinics and tumor
               registries.
               The budget for 1971-72 includes funds for 25 full-time positions, 22 of
               which have been filled.- The new positions would be a Systems Coordinator,
               Nursing Specialist and receptionist.
               Continuation support in the amount of $76,215 is also requested for three
               projects:

               #9   SVRMP Information Service
               #16   Radiological Health Training Program
               #17   Columbia-Montour Home Health Services

               Renewa
                                                                                  3rd Year
               Project #6R - Coronary Care            aining Program, Geisinger  $29,425
               Medical Center   The Geisinger Medical Center will conduct





               SUSQUEHANNA VALLEY RMP             7             RM 00059 2/71.1 (AR-1 CSD)

               four,, four-week coronary care courses per year. Each  class  will  admit
               ten trainees, who are principally recent  diploma  graduate  nurses.  The
               curriculum includes lectures, laboratory work,  and  clinical  experience
               in special nursing techniques for the cardiac patient.
               Community hospitals throughout the Susquehanna Valley Region, as well as,
               border areas, may use this training program to staff their coronary care
               units with qualified nurses.
               This project was submitted with the Region's initial operational applica-
               tion and applied for and received one-year renewal support last year.
               Since its inception, it has trained 42 nurses.

               Fourth Year
               $31,551

               Approved but Unfunded Projects
               These projects have been previously approved by Council, but due to nation-
               al funding constraints, have not been funded.  Committee and Council con-
               siderations of these projects is needed in determining an overall funding
               level for the Region for the next year and not for approval of the
               activities.
                                                                                lst  Year
               Project #18 - Rheumatic Fever Control Program.  This project     $15,217
               will impress upon physicians and the public the necessity for
               throat cultures in diagnosing  streptococcal  infections.  Hospitals  and
               physicians in 16 of the Region's 27 counties will receive free throat
               culture kits.  The-kits will be used on people between the ages of    two
               and forty-five who have upper respiratory infection or a sote throat.
               The participatin  hospitals will interpret the cultures and send reports
                               9  ,
               to the attending,physicians.  The physicians will follow-up with appropri-
               ate treatment.
               Although this project involves the demonstration of patient care, the
               aspects of continuing education are also present.
               In addition, the promotional efforts of the Heart  Association,  who  will
               participate in the program, will increase the public's  awareness  of  the
               value of the procedure.


               Second Year
               $641,417
                                                                                lgt  Year
               Project #19 - CatdiO2ulm6nary Resuscitation Ttainia&.            $169  693
               Sponsored by the Heart Association, the purpose  of  this  project
               is to establish an emergency  cardiopulmonary  resuscitation  team in every
               hospital in the Susquehanna Valley Region.




                                                        8                RM 00059 2/71.1      (.kR-1C
                SUSQUEHANNA   VALLEY   RMP

                                                                                          pit@l@will
                First, the Instructor s Training     Center at   the Harrisburg   Hos
                be expanded to include a special     training course in emergency cardi@
                pulmonary resuscitation.  Each year, teams from 18 hospitals will complete.
                                                                                of the Penns@lv     L
                this course.  Then, using    the    organizational    framework
                                     nd its  chapters,  th  se  n  ly  @rai  ed  t  ams   will   tra
                Heart Association a      1                   e    e@          ii   e
                other hospital teams.
              'The wide geographical     distribution of   emergency teams    will  be   ideal   for
                training  local  ambulance  crews,  rescue  squads,  and   other   health   personnel
                throughout   the   Region.
                Second   Year                                           Third Year
                $15,481,                                                $160066
                                                                                         ist Year
                Project   #21  Enterostomal Therapy Training.  The Harrisburg            $9.934
                Hospital will conduct twelve, four-week courses-in enterostomal
                therapy per year.  One student will be trained in each course.
                Training  will  include  bedside   instruction   and   practice  medical    lectures,
                technical lectures, and conferences.
                The graduate therapists will be able       to. rovid6 patients with     stomal  care.
                                                              p
                         g  ent, therebyfr     ' g nurses and physicians for-other       work,.    In@
                and  mana  em                eein
                addition,   the   therapists   will   instruct                e  -care  and  teach
                                                              patients in s lf
                allied health personnel the principles 6f.stoinal management.
                Second   Year                                           Third Year
                $10,439                                                 .$10,920
                Project #25 - Altoona Hospital Training Program.for Coronary Car(--          lst   Year--
                Nurses.  This project will provide four, four-week coronar            are     $593,873
                                                                                  y c
                training programs per year to primarily registered nurses from
                the Appalachian-Highland,Area.  Training will       consist of didactic.
                .1edtures and clinical experience in thelhospital'8 classrooms,.
                and will be taught by its physicians and nurses.  Consultants from
                other areas will be called in to teach special subjects.  Each
                program  will  teach  nurses  the  use  of   monitoring   equipment,   defibrillators
                and  EKG  interpretation,  as  well  as   spec.ialized nursing skills
                required  for  high  quality   cardiac   care.
                The  program  is  expected  to  become  self-sustaining  in,the   third   year through
                thitigh fees and..the voluntary teaching and      supervisory services      of    the
                professionals.

                Second   year  $59,873

                New Projects
                                                                                           let   Year
                Project   #27   Nurse Dial Access,      Robert Packer Hospital.-            $29@969.
                Sayre,   Penn  lyania.  Dial Access     for Nurses  will.cover Central
                New York State and the entire state of Pennsylvania.            It is a special
                telephone  information  system   for   RN's,   LPN'S,   student nurses,  and others---
                particularly those practicing in       an isolated setting -- who do not have the
                resources available for their continuing education.  Available on            an around-





               SUSQUEHANNA VALLEY RMP          - 9             RM 00059 2/71.1 (AR-1  CSD),

               the-clock basis from any telephone, it provides the caller with free,
               five-to-six minute taped messages on a variety of subjects, suth.as
               (1) nursing care for specific conditions, (2) new procedures and equipment,
               (3) availability of community resources, (4) nursing care in emergency
               situations, and (5) legal aspects of nursing situations.
               The   Central New York RMP is presently funding a Physician Dial Access pro-
               gram  out  of the Sayre Hospital.  SVRMP Core funds are being used to exten4
               coverage   of the physician program to their Region.
               Second   Year                                     Third Year
               $29,453                                          -@30,224
                                                                                 Ist   Year
               Project   #28 Automated Computer-Assist6d Analysis of the           $294i470
               EEG, Pennsylvania State Universay.  Four.participating hospitals,
               located in three areas of the Region, will  send  computerized  EEG  signals
                                                                                'll be
               to Penn Statel,s Hybrid Computer Laboratory.  The information wi
               interpreted by computer at Penn State and  the  diagnosis  returned  to  the
               sending hospitals. Each computer diagnosis will  be  compared  to  the  phy-
               sician's final diagnosis.' The purpose of this project  is  to  install  and
               further develop this computerized EEG system    and at the same time, deter-
               mine the feasibility of providing all hospitals throughout the Region with
               rapid and valid electroencephalogram interpretation service.
               Since January 1968, the Geisinger Medical Center and the Pennsylvania
             "State University have been conducting research on automatic computer analy-
               sis of  EEGS.


               Second   Year
               $82$1062
                                                                                 Ist   Year
               Project   #29 Computerized EKG Pilot Program.  This project         $300,186
               would establish a computerized EKG transmission and analysis
               system which would link'13 hospitals in a 27-county area to a    computer
               center.at Harrisburg Hospital.  EKG's would be transmitted to    the center,
               processed and the interpretation transmitted to the originating hospital.
               A formal training program, conducted by  a  cardiologist  from  the  Hershey
               .Medical Center is planned for physicians and technicians  involved  in  the
               project.  The project resulted from a pilot program at the Harrisburg
               Hospital.
               Second   Year                                     Thir-d Year
               $3009186                                          $300 186
                                                                                 !6t   Year
                                                                                 @ i Ol 6 -, T2-8
               Project   #30 Coordinated Home Care Pto4ram of Lancaster
               County'  The Coordinated Rome Care Agency.of Lancaster County
               will  arrange quality medical, nursingo  social,  and  related  services  for
               patients in their homes.  The central administrative Coordinated Home Care
               Agency  will:





               StjSQUEHANNA VALLEY RMP              10            RM 00059-2/71.1 (AR-1 CSD)
               1. Coo   nate  community   reso         he delivery of o tim= home health
                     rdi                     urces in t                  p
                  care  services.'
               2. Act as the one  source-of  referral  for the physicians,
               3. Serve  as a center  for comprehensive planning, evaluation, and follo,wup
                  of home care services.
               4. Act  as an information service for physicians, patients, participating
                  agencies,  and.the   public.
               .5. Hold periodic'joiht conferences with physicians, other professional or
                  allied persons, and consumers of service to      determine how effectively
                  the program is functioning.
               Second Year                                         Third Year
               $106 367                                            $115,400
                                                                                  18t Year
               Project #31   Family  and  Community  Health  Service Pro  M       $145.0630
               Lancaster G6netal Hospital.  The main objective     of the Family
               Health Service Program is Lo deliver comprehensive family-priented, pri-
               maiy health care as part of a community   'hospital.  The new system also
               seeks to create A structure which casts   a physician as  a health advocate
               for his patient.  Home health aides will be used t   o provide health educa-
               tion and develop communication with the   clientsi  Residents.of the low
               income areas will serve on a board to review and analyze the effectiveness
               of the delivery system, which includes Family Practice Residents and
               Nurse Practitioners.
               Second Year                                         Thitd Year
               .$145,724                                           $i59,086
                                                                                  lst Year
               Project #32 - Central Pennsvlvania Cancer Education and            $296-,178
               Treatment Center, IAltoona Hos2ital.  This project will provide
               physical facilities, equipment, and personnel to conduct a cancer education
               and treatment center.  It will utilize cobalt therapy, deep therapy  and
               isotopes for diagnosis and therapy and provide a firm basis for continuing
               education for physicians in cancer detection and treatment.  It will also
               provide.a super-voltage facility in an area geographically and economically
               separated from the nearest similar facility by more than 50 miles, as well
               as allow for continuity of treatment, detection of recurrences, and new
               primary tumors, while maintaining identity with the patient's personal
               physician.  The Region's Ad Hoc Committee on Radiation Therapy, which is
               ;studying the Region's radiation therapy resources, has reviewed the project
               and endorses the need  for  a  facility  in  Altoona.
               Second Year                                         Third Year
               $202,075                                            $210,050






           SUSQUEHANNA VAL LEY RMP                            RM 00059 2/71.1 (AR-1 CSD)

                                                                           lst Year
           Project #33 - Hamilton Health 'Center. The  Hamilton  Health    $147,175
           Center, Inc., a nonprofit organization directed by a  group of
           consumers and representatives of providers of health  care, request
           support to establish a comprehensive health care system  in a disadvantaged
           area of Harrisburg.  The neighborhood health center will be served by a
           family health team, which includes community health aides recruited from
           the neighborhood.

           Second Year                                     Third  Year
           $457,811                                         $678,897







































                                                            GRB/RNPS  12/28/70









                                                                                                                                                 CTOR




                                                      Asst      :)-rec"or                                                                                                           Isst i
                                                                for
                                                                                                                                                                                   Proere
                                                      Tec,in,.cal-        Se--v


                                        Graits                                                                                                           Ed,,ica' ional
                                                                            Syslems                                     Co-@muni                         Ac-.-;-viti-es                                               ervice
                                                                                                                                     P- -@or
                                                                                                                                                         Coordi-na'.or
                                        Coordina'@or                        Coordinator,                                Coordin                                                                                       oodina,orl:


                                                                                                                          CoirL ni@c                                                 el-d
                                                                                                                                   i-L                !'I%7ur s 4- n g,                                                                   d               Fuels
                                                                                                                        S?,)ecialist;                                                                                                                     Reprcse-
                               PC- -1--i- 2s
                                                                                                                                                                                 Fa
                                                                                                                                                                                 Re   or                                            e     ese.










                                                                                                                                        Secrel@ary









                                                                                                                                                                           S-IAFP @NIZATIO-N
                                                                                                cept
                                                                                                                                                                           VA,@ REGic,%'bL fl.:-DICAL N, CrzRA,%l





                                                13-

                                           C),'@ [iEA!--I'H, EDUCATIO,',4, A@.D WELFARE

                                              FIUPL.IC !IEALI'H
                              HEAI-TH  S2RVICES  AND  I%IEN-RAL  HEAF-TH  ADtv',INISI-RATION


        I)c!e: Dt,cciTiber 23,  1970
      Repb- to
      Altn oj.
              ,;t,iff Revi(--tj of Iloi-i-Conipc,,ting Cc,ntintiation Appli,cition from the
       S!Ivect: Su,-,(Itlciiiiiii@i Vzlllc@y Rc,.gioiiil @ledj-c,.il. Pro-rim, 5 G03 l@M 00059


                                  Pi-c),-rim@; Service


                                 ',Ioii Lli
                            Llic i

              AL-tillt@ Chief, Re@,,ioii@il I)evclopTli(.@tic Bralicli

              Chief, CrziiiLs Manigoment   Branch

              Acting Cliief, Grints Review Branch


              The SUSqL!eliaiina Val.ley Regional Medical Program j.-, requesting, continua-
              ti.on support for its 03 operational. year for co.-c.- and three projects.
              Since Susquehanna Valley's bud-et yeir does not start until April 'k, 1971,
              and  'tit(:!  45-day  estimate   of   expenditures   is   not   due   until   mid@February,
              requests for use of carryover funds have not been included in the present
              application.   Therefore,   the   discussion   was   limited    to    general    prQ-raT.,l
              issues and the following continuation request.

              Continiiat ioti Reriuest(,@d                                 Amount

              Cor@                                                           $469)700

              Project #9, SVRNFP Information Service                       45,614

              Project #16, Radiological Health Trainiii-
              Program                                                      173,  501

              Project #17  Columbia-Montour Ilome Health
              Services                                                     1 3, I.O(J

                             Total                                          $545,91.5

              Besides the continuation request, the Region has included in its.AR
              application, a request for a developmental component, funding of four
              approved   but   unfunded   projects,   a   renewal.   and   seven-now   pIro4ccts.       The
              Region was supported by a fundin- leiel of $671,997 during the 02 year.

              1'ecomaienda L !.on: Approval   of   the   committed   amount   of   $545,915   for   core
                                  and three projects.






                                                                       December 23,.1970
               Harold Margulies

               The following staff members attended, the    December 17.  meeting:

                                    Miss Dona Ilouseal, GRB
                                    Mr. Dale Robertson, RDB.
                                    Mr. George Ilinkle, G@IB
                                    Miss Mary Asdell, CEB
                                    Mrs. Patrici.a M61.1ins, PFB
                                    Miss Loretta Bro@-in, PEB


               General Coii,@iiioiits
               Staff was pleased with tli-I.,i Rc,.gion's progress dtirini,, the past ycir.    Vlhile,
               this Region is only beginning to deil. with the setting of more specific
               goals and objectives ind i.s just starting to co]-l.rct needed data, its
               efforts in col)iiig with some  of  the  problems  identified  by  the  site  visitors
               and reviewers last year were encouraging:
               1.  The. evaluation reports by a physician consultant of the five termina
                   ting coronary care projects, which have been sorely needed, have been
               included in the application.  The &Valuation reports incl.uded with the
               termination reports appeared thorough and the criteria developed should
                'eye valuable to   the other non-RMP funded units developed around the.
               r
               p
               -Region.
               2.  The SV@IP core   staff including the Coordinator is completely lay.
                   While this type of core'can function with imagination and work very
               capably, in the past this has not always been the case.         Several kinds of
               capabilities were missing from the staff and this weakened the program
               For example, the continuing education se--@nent-has been marked by frag-
               nientation'and a lack of awareness of what has been done elsc,,ilic-re.      Sonib.
               of this may be solved by getting outside consultation (to be discussed
               bel.ow), but Core staff is also adding needed expertise in continuing
               educatioii-and allied health.    A program development director, systems
               coordinator and a research-and cvaluat4-on specialist are also being era@
               ployed.   Problems  with-the Regional Advisory Group caused by poor com-
               munic,it:ions have  prompted  the  staff  to  spend  more  time  personally  advising
               the RAG members of SVRMP activities and changing the presentation of
               written  material  going  before  the  RAG.
               3.  As a  result' of site visit recommendations     in  February  1970@  the   Region
                   has sought consultation in plannin-.  A group including Marshall.
               Raffel, P&nn State University; Dr. Joel Nobel,       Emergency Care Research-
               Institute; as well as' state health departricnt and Bucknell University
               personnel was  "called tocether to advi.se on the structure and composition
               of  a  prbp6sed-Planti'l-og  Committee.  Th.ere is also evidence that the Region
               has sought outside. expertise in various technical areas.
               4.  The review proccs@; is being strengthened.       Formal review procedures
                   includiii,, a set of criteria  and  a  numerical  ranking  systerii  which  gives





                                              15-

            Harold Margulies, M.D.                            December 23, 1970


            all- new projects a priority number, have been devised for the @.C.
            Plans are underway -to develop a similar system for the Councils and
            Area Committees.

            5.  The relationship between the RMP and the -rantee a-ency  the Pennsyl-
               vania Medical Society, has improved slightly. 'The Medical Society
            still considers the rMP as a branch of their organization and maintains
            a degree of control consistent with this concept.  Discussions have been
            held with the. P,@IP and grantee agency conccriL-I.ng the establishment of a
            nonprofit corporation,, but at the present its establishment seems 4 long
            way off,
            Conclusion:  Approval of the committed amount of $545,915 is recommended
                         for the Region's third operational year.



                                                      Dona E. Ilouseal
                                                      Public Health Advisor
                                                      Grants Review Branch


            Action by Director


            Initials


            Date





                                         -16-











                                                            'Tanuwy  4





           Mr. Dale Robertson
           Programs Assistance Branch
           Regionaa Medical Programs Service
                                ntal Health Administration
           Health Services and 14e
           Parklairn Buildingg, Room 15
           5600 Fishers Land
           Rockv,iUe, @land     20852

           Dear Dale:
                This is to officially inform you that we are withdra@ Project
           No. 2-6. cardio-pu3.monwy and CVA Tr-=sport Vehicle. The reasons  for  this
           vithdraval                      attf                cant, Robert  L.  Evans
           M.D., which is enclosed with this letter. 'ge are  pldased  with,the.honest
                                    s inatitution.&nd, tl-iere:tore,.            th
           evaluation offered by thi                              must cbncur vi
           the request.
                Although Project No. 26 has already been  approv ed by the ',':,,&howl
             isor,y council, it should no longer be considered  a  p@  of.our  request
           Adv
                          o= Annual Application submitted November   il 1970.
           for f=ding in
                                                   sincerely yours,



                                                   Richard B. McKenzie
                                                    Dirtet6r


           EBM:jz

           Enclosure

           cc:  Miss Dona liouseal
                mr. George Hinkle
                Mr. Clyde Ccruclman






                                                                                           DEC 2
                        O,-- tl@-I)ICAL EDUCATION
                                                  -17-
                 I.. E:VANC',. fi.D.-DIP,@c-.CTOFZ
          LEON T'. 1,NDFZE@VS. Ni.D.-ASSOCIAI'E: DIRE:CT07%                                WoIa Copy
                   t-1. F,'--ILLY, t.l.D.-P@-'DIATI@ICS
          DAVIC) Ni. SHEAFIER. NI.D.--lt4TEi?NrL NIEDICINE
          'rtIC),VAE; tt. HAFZT. NI.E).-F-A,',IILY FI@ACTICF-
          E)AVID J. JONES. NI.D.--CONIMUNITY ?,IEDICINE-:



                                                                      y cj f:.--
                 Decohibcr 24'.1970


                 Mr. Richard B. @IcKenzi.e
                 Director, SusquchantiEt Valley
                   P,eg5,6nal medical Program
                 13.04 Forn%iood Avenue
                 CImp Jij.3.1., Pennsylvania  17011

                 Dear Mr. McKenzie,:
                 In reviewing out application for "A Cardi.o-Pulnionary and CVA
                 Treat-=nt Vehicle", it is our understanding that this appli-ca-
                 tion  has  been   approved,   and   is   awaiting   funding   through   the
                 a.ppropriations bill recently passed by Congress.
                 The  original  application   for   this   project   was   made   over   two
                 and one half years ago, eihen it was designed as a feasibility
                 study directed at special services to patients suffering from-'
                 coronary   and    6erebro-vascular    problems.    In    the    intervening
                 time, it has been shown repeatedly, both in the United States,
               .and abroad, that this service has questionable justification.
                 it is probably neither financially or professionally efficient,
                 as first thought, nor a good use of over $200,000.00.
                 Although we realiz    c thit this.project- has been        approved     for
                 funding,
                            and will be fundedi we should like to           withdra,..i  our
                 application.  We  simply  do   not   feel   that   the   project   is,   at
                 this  time,  a   justifiable   use   of   tax   dollars   with   reasonable
                 chance of productivity for our people.
                 We hope you will: undcrstend and agree -with our decision, and that
                 we May work together in the futu'xe on a mo2,o productive application.
                 With valid best @iishcs for the      Holiday season,

                 Sincerely  ours,
                             y



                         L. Evans,    M. D.
                 Vice President -     Medical. Affairs

                 RLF,:njh
                 cc;                Bro,,,,nc,].).cr, M. D. 'Fecretai,y of flo@iltli
                       Harold kl,-trVul.es, 1,1. 1)., Acting Director DIZIll"



                                                                      Region         SLISqUChanna Val@e
                                                              -18-
                                                                                                                                        YC3-:  02.
                                                                                                           Current  Opc-ration.-Il
                  procrpt,i @ruii(linc@:                                                                                                             'i '  0
                                for Ctirrc-nt Yeir        --------------   $.6,66,495                      Fir:;t Sclicdti @d AR applicatio
                                                                                                                 In         cycle
                                                      nt      Year
                   opcriLiii?, level  in CLirri                               671,997                      negion's optional plans: Norte
                   (includes         funds c@irrica,     for-.jard) -------$
                   Recorri,iendcd Co:nriLtr.,.cnt   for next Year        ---$ 545,915


        CO'IPONENTS BY DISEASE CATEGORY                          P.ROPOSED.CO,-'PO@IENIfs                                    CO','I?C'@IENTS BY TYPE     OF  %CTIVI
                                                                                                                       TRAIII,I:C, A,;D EDUCATIO!;
      @RT                                                           N@T  PROJECTS
        Cn-g,3ing                                                                                                            On-going
                                                                                                                                   Projects.   4
           0    Projects    5
                                                                 Project      #27-Nurses                                        Total  $S      85,872
           Tot-11  @s 37 578
           %    $S    5    6                                     Dial Access                                                    % $s 12.8.
        Approvcdiutlf,,nded       -0-                                                                                        Approvcd/oinf-indr-d  0
                   yq4     8                                                                                                          r qy,,A    6

      :C@.R
                                                                              #29-Computer-
                                                                 Project
                                                                 ized      EKC,
                    Projects2      -
           Total  $S       14,042                                                                                      DE'-IO'NS'r?.ATIO',i Or' PATIE.NT CARE
           %    $s    2    1                                                                                                 On-poing
        Arpro,.-cdlunFiinded -0-                                                                                                   Projects   7
                                                                                                                                Total  $S      I 10, 925
        Disapproved        -0-
                                                         z%-         Project  #32-Central  Pa.                                  % ss 16. 5
      ,OKE                                                                                                                   Approved/unfunded  -0-
        On-going                                                 Cancer EdtcatiOn 4nd                                        Disapliroved  5
           ,4   Projects    I
           Total  $s   52,982                                    Treatment          Ce.nter
           %   SS    7.    9
        Api-iro-@,ed/unL'Yli(led       -0-
        Disapproved                                                                                                    RESEARCH & DtkrZLOP,'-@-',T
                                                                                                                             On-going
      ),','F Y                                                   Project  lf28-Automated                                        # Projects
        N-going                                                  Computer-assisted                                              Total $S
                    Projects                                     AnAlysis      of       EEG                                     %    $S
           Total $S                                                                                                          Approved/tjii0tinded
           % $S                                                                                                              Disapproved
        Appro%,edlt!iiftin(icct
                                                                 Project-#33@Hamilton
      '.I.A'fED     DISEASES
                                                                 Health  Center
         Oil-going
               Projects                                                                                              ADMI,';TSI'RATIO'4
            Total         $S                                                                                           On-roinp
            %    $s                                                                                                          Projects     I
         Approvcd/unfutided                                      Project  #30-Coordinated                                 Total      Ss 475,200.
           is;-g,Droved                                                                                                      $s    70. 7
                                                                 Home Care  Program of
                                                                                                                       Ap,,)rovctl/unfuiided 0
      ii      TICAT@.GORICAL                                     Lancaster                                             Di,.;tppr'oved           0.
         On-poing
               ',Irojec@S'  3
            Total $S  92.1195
               Ss         13.7                                   Project  #31-Family  and
         Approved/utifuntlcd           -0-
                  roved     1                                    Community  Health
                                                                 Service  Program,
           AL
                                                                 LaAcaster-

            0       Projects
            Tot.11 $S  475,200
               $S'      70.7
         @pprove(l/uii(tikidcd  o
                                  0




                                             -19-
                                                            Region      Susquehanna Vallev                              -2-
                                                                                          Current operatio,-l@-il Yeir:  02
                            for Ctirr(-nt Yeir     -------------- $.666,495            t  Fir3t Scii(fl,'Ll cld  @R  application
                 Operating level in Cticrcnt Year                                              In        cycle
                                                                  671,997
                 (inclu(ics  funds  carried   for-.jard) -------$                         Region's     optional      plans;      Noiie
                 R6corr.incndcd coi,.iii)iLr.,,cnt  for next year   ---$545,915


        CO'IPONEN'ES BY DISEASE CATEGORY               PROPOSED   C O' .',P 0'4 E Nf S                   CO@IPO,F.NTS BY TYPE OF ACTIVI
   ,EART                                                                                             TR^INII:C    AI;D    ZDUCATIO.'4
        on-going                                  Approved but Unfunded                                  On-going
          # Projects 5                                                                                      # Projects     4
          Totil $S 37,579                                                                                   Totil  $S   85 872
          7   $s   5..6                              Project #19-CPR                                        %  ss  12.   8
        A @ivovcd/uii[kindcd       -O-                                                                   Appro,vc-d/,jnf-indcd  0
                                                               ing
                 oved 8                                                                                                   6

   :A','.CFR

             Projects    2,
                                                              t #18--Rheumatic
          Total $S   14,042                                                                                          OF PA'flF..4T CARE
                                                       Fever Control                                     On-going
          % $S 2.1
        Api)r,)vcd /U',l f LI nded -0-                                                                        Projects   7
        Dis.lpprdved         -0-                                                                            Total $S    110, 925
                                                                                                            %  ss  16.   5
   3TRO.U                                                                                                Approved/unfunded  -0-
                                                       Project    #21-Enterosto-                         Disepiiroved  5
        On-going
             Projects
                                                       mal Therapy Training
             tal $S   52,982
             $5    7
             O%,Ed/unfynded    -0-
             pproved                                                                                 RESEARC@  & Dt--':ELOt;-'@Ell'T
                                                                                                         On-going
   (IDNEY                                                                                                   # Projects
        On-going                                                                                            Total $S
          4' Projects                                                                                       % $S
          Total $S                                                                                       Appro,.,i-,rl/,infk3nd6d
             $S                                                                                          Dis,3ppro,4vd
        Approved/t!iiftindect
        T)is,l,-r,ro-ed

    P,ET.A-@Fr) DISEAS@.S


              Projects
           Total $S                                                                                  On-r,,oinp,
           %     $S                                                                                      Projects  I
          Approved/iinfunded                                                                           Total  $s  475,20.0
                 -roved                                                                                '7  $S  70, 7
                                                                                                     Ap,-)rove,',/Liiftjiided 0
                                                                                                     DJ!3.qpproved       0

          On-poing
           ,I ',Irojects'  3
           Total  ss  92,195
           7. $s  13 . 7
          Approvc-d/utifijn(led  -0-
                        1



          On-p.olne
           "  Projects  1
           Total      $S      475,200
     07. $S' 70. 7
                                  0
          Di,z,-ii,@roved     0







                                                                                                                    SUSQUEHANNA VALLEY
                                                                                                         REGI
                                                                                                          CYCL
                                                       BREAKOUT OF REQTEST            3          PERIOD


                               OF
                                                                            iAPPR/UNw
                                                                                                              $54,596                    $54
                                                                                                              469,700                    604,


                                                                                                                                215         22,711
             016-Radiation Healt        I g.        17,501                                                                      -
                                                                                                                                            13,10,

                                                                        5                                       29,
                                                                                                                75,217    NOHS
                                                                                                                16,693                      16,6
              @19-CPR
                                                                                                                     934                    9,934

                                                                                                                                            59,8
                                                                                 59,8-,                         59,873
                                                                                                  29                 969                    21,S
              @27'-N-,irse Dial Access
                                                                                                                     470                    319,280
              @28-Automated EEG
                                                                                                      186       300,186                     300,186
              @29-Computerized     EKG
                                                 t
               i3o-Coordinated    Home  Care     I
                                                                                                 145
                       ily&Cmm. Health
                                                                                                                                            296,
                                                                                                 29
                          r Ed.  1, 'Krea 1:@
                     inc'
               f32-C ncLr Ed.    & Treat ent                                                                                                147,]
               @33-Hamilton Health Cen'
                                                                                       17      1,374,332                                    302,6
                                                    545,915         29,
                                     TOTAL
                             t costs  to be negotiated
                    Indirec






                                                                                                                      REGION     SUSQUEHANNA      VALLEY
                                                                                                                        C@CLE   RM 00059 2[71.1
                                                                  BREAKOUT OF    REQUEST          04         PERIOD


                       IDENTIFICATION OF                  ICONTINtl@G                   PREVIOIJSLY'      NEW
                                                          I              I
                                                          IAC-IVITIES    RENEWAL               APPR/UNFUN.IACTIVITIES    DIRECT      'INDIRECT         TOTAL
                       CO@TO'%ENT
                       Devel pmental                                                                      $54,596             $54,596                  54,596

                       Core

                         9-Library Info. Service

                                             th Trng.
                       @16-Radiation Real

                                   _a'lth Service
                       IFL/-MOMe Ho
                                                                                                                                         9,40          40,953
                       p6R-Geisinger CCU Trng.                               31,551                                         31,551            2
                                                                                            64,417                          64,417       NONE          64,417
                       @18-Rheurnatic Fever control
                                                                                                                                                       15,481
                                                                                            15,481                          15,4,81
                       IFI4-CPR
                                                                                                                            10,439                     10,439
                       1021-Enteros. 'Meral                                                 10,439
                                     CCU T                                                  59,873                          591873                     59,873
                       it25-Altoona
                                                                                                               29,453       29,453                            53
                       ,it28-Automated EEG                                                                     82,062       82,062      25,92-5        107,987
                                                                                                           300,186      1   300,186        k           300,186
                       @29-C@puterized      EKG
                                                                                                           106,367          106,367                    106,367
                       lP30-C6ordinated lioT-,e  Ca're                                                                           A                                     I
                                               Health                                                      145,724          145,724       NONE
                       [431-Fa-,nily & Co                                                                                                              145,724
                                                                                                           202,075          202,075                    202,075
                       #32-Cancer Ed. & Treat!nent
                                                                                                                                                       457,811
                       1#33-n,-.,-,iilton Health Center                                                    457,811          457,811
                                                                                                                             1,@0,035    35,327        1,595,362
                                                                o             31,551        150,210       11,@378,274
                                              TOTAL        I              I                            .i                i                                              i
                                 Indirect   Costs   to   be !negotiated











                                                                                               BR,--AKOUT  07  RE@,UEST                          PERIOD
                                                                                                                                                                                                          @l 00059  2/71.1
                                                                                                                                                                                                                               iL          Y-LARS
                                                                                                       U S L Y                                                                                        D                        '@)TAL
                                                                                                                                                                                     TOTAL
                                                                                                                                                DIRECT
                                                                                                                                                                                                                8s            Is         '6357,08
                                                                                                                                                                                    $  54,596 ;!$163,'
                     le,,el         o:)mer,tal
                                                                                                                                                                                                    :$469     700                       604,@c5u'

                     C,? r c,
                                                                                                                                                                                                         45
                                                                                                                                                                                                             @614              S           63,033

                          Fo.      Ser,,,,i-ce
                                                                                                                                                                                                                                          n-2,716

                                   Trig.
                                                                                                                                                                                                     's  13,100
                          7
                                   e
                                   Servi
                             C.@;s          nger:


                      'Fe-.-er          Contro                                            ;s        16,066                                                                                    0
                                _CF?
                                                                                                                                                                                                                               5    31,2
                                   @,2 ro S  -                                                                                                                                           10,920       -S  31,293
                                                                                                    10,920
                                      Trr's.                                                                                                                                                                                              1!9,746
                                                                                                                                                                                                      1$j

                       C'-
                                                                                                                                                                                                           89,646              1 $         89,6"6
                                                                                                                               $30,224         $30,224
                                        Access
                                                                                                                                                                                                            6
                                                                                                                                                                                                      @$37  .,532              Is         427,267
                                                                                                                                                                                                           00,558              I$         900,55S
                                                                                                                                                       186
                                                                                                                                              $300                                     s-,oo, is
                                                                                                                     :5300,186
                                                                                                                                                                                                                                          327,S95
                                                                                                                                                                                       $115
                                                                                                                     ;@l@'-5,400              $115,400
                               Fo7io        Care:
                                                                                                                                                                                                        $'50,440                          450,'40
                                                                                                                                                                      O\ E                        -   il'                                       -
                                                                                                                                                                                       $159,0,@
                                                                                                                                                                                                                               !$         708,303
                                                                                                                                                                                                           08,303
                                             la                                                                                                $?10,050
                                                                                            i                        !$-10,050
                                                                                                                                                                                                                               '$1,283
                                                                                                                                                                                                             26'3,8S3
                                                                                                                                                                         ?C            $6, 8, 0,97,
                                                                                                                     :$678,8'),-'              $678,897
                                       o@,  te  r
                                                                                                                                                                                                                                    4-,3 .4  'L,4
                                                                                                                                                                                                                               @$5
                                                                                                                                                                                                              2 4 6  8.4 1)
                                                                                                                                                    575.42@              0
                                                                                                                             5,, c;   39
                                                                                  0                   2 6   9 S(

                                                         to   be






                                                     -23-
                                                                       (A Privileaed Coiiimiinicatioiii


                                       S@,IMARY OF R-r-,VIE@,l AND CONCLUSION OF
                                                /'-CT;'-D I:)TT AT)-,7  1 Ci -71 T)@vy'.
                                               I I Ail, L;.,.I    I\i@ v i.E
                                                                          CYCLE


                                SUSQUEHANNA    VALLEY REGION-AL   MEDICAL PROGI.Qdl
                                               RM 59 (1@R-1-CSD) 5/71.

                               @,7
                       FOR COz',SI-DEPJkTIO@T BY APRIL              AND Yu%Y 1971. COUI,,"'Il@

              RE,CO',,@,IENDAT'10'7:  Committee  deferred  tl@eir  recommendation  on  all  but  the
                                   renewal  Project  il6R  (which  was  ipprovecl  as   requested)   to
              Council with the     sug,-esti-.on  that  a  site  visit  be  scheduled  to  the  Region
              before  the  Cou@-icil.   meeting, (Subsequently,   the   Director,   PIIPS    determined
              that  a  sil'te  visit  would  not  be  scheduled  at  this  tiiie.)  The  Re-ion  has
              requested  new  funding  in  the  amount  of  @4,581,188   for   renewal   of   one
              project, four previously approved but unfunded projects, seven new projects
              and a developmental component for a three.-year period.

                    The amount recoaLniended for project ljr'611,, is:   01    $29,425   and   02
              $31,551@
                           The Susquehanna Valley l@-',,IP's application was difficult to evaluate-
              because  the  Recion  is  undergoing   several   major   changes   and   the   Committee
              had  no  member  with  on-site  knowled-e  of  the  Re@ioii7   (The   member   who   had
              chaired  last  yearts  site   visit   has   since   left   the   Committee,)   Several
              problems were identified by the site visitors           last  year,  and  the   Region
              is taking steps to alleviate them.

                    The Core staff, including the CoorrJinitor, is completely lay and
              without  corib,,-ned  significant  experience  in   the   health   planning   area.
              Although.lay staff can function with iiii@-citiation and work very capablytl-ie
                                                              LI
              ',Susc            lley l@'2 Stpli@-- needs additional capabilities in order to operate
                  .Iuebanna Va
              in  this  manner.  The  low  salary  scale  which  has  been  set   by   the   erantee
              agencyi  the  Pennsylvania  I-,Iedical   Society,   has   been   partially   responsible
              for the difficulties in getting highly qualified personnel.  Several kinds
              of capabilities, particularly in continuing education, all.4@ed health,
              and  evaluation,  were  lackina  and   this   weakened   the   program.   During   the
              past  year  the  Region  has  hired  a   continuing   education   director,   a   program
              development  director,  a   systems   coordinator   and   a   research   and   evaluation
              specialist.  The  Region   has   sought   constiltition.e)-,pertise   in   planning   and
              evaluation,  as  well  as  in  various  technical  areas.   A   group   of   planninc,
              experts   from   Pennsylvania   State   University,   Bucknel.1   University,   and
              the  State  Health  Department,  amono  others,  has   been   called   to(,Ptlier   to
              advise  on  the  structure  and   composition   of   a   proposQd   Planning   Committee.
              A  physician  has  been  retain,.i  as   a   consultant   to   coordinate   evaluation
              of  the  coronary  care  units  in  the  Recion  includiii-  Tany   which   were   not
              funded by tie SVP\l@IP.

                    Progress  has  been  made  in  the  continuing   education   segment   o'L'tlle@
              program.    The newly ap,,)ointi-d Continuing Educnt-Loii Cc)oreiiiintor on Core staff
                   worked with
              has                 the   Continuing   Education   Council,   ?hich   has   restructured
              its membership to include wider representation frora nonmedical professions,





              SUSQLFEIJA@'diA VALLEY IdjP                -2-


              to  look  at  tl-te  quality  and  accessibility  of  health  care  on  a  regional   basis.
              The staff has also r,,ouaht consult,.atio@,i in -,Il.ied lic@ilth  from  i  neigliboriti-
              Region  and  tal@en  steps  to  strengthen  the  continuiri-  education  co@,iponent   of
              ongoing and new projects.

                    The heavy eir@plinsis  on.  coronary  care  during  the  first  two  years  of  the
              prograri  has  been   ameliorated.   Viie   present   application   includes   requests
              for  comprehensive  health   care   centers,   home   health   care   coordination,   nurses
              dial  access  pro-rani  and  a  computerized  l,',IOLG  proposal.  The  only  oncoin-  coro-
              nary care proposal would be the Ceisen,@,,cr                Center CCU iqurse Training
              Program,  the  sole  such  resource  in  the  Re-!.on.  The  proposer   of   an   already
              approved project (i'r'26), 'the-York                    withdrawn   its   request   for
              a CVA Transport Vehicle bE,@ce-.-,@se they believe it is no longer -I ;qise use
              of Federa@. funds.

                    T'ne Re,-,i.orial. Advisory Crotip has formalized their review criterii and
              developed a numerical ratn, systeL-ii  i.-,Iiich  assicns  @i  nurcterical,  priority
                                               I                     C,
              to c,@ich- project,  Plans are   under consideration for the adoption of a
              sii-,iilar sysL:e@ii for the Co-Lincils an,] Area  Coinnittees.

                    Comroittee noted that onl,, sli.-lit )'-iiiprovei-net-it had been made  in  the
              relationships -,;,Lth the Ilersliey  1,1@edical, School and tl@-Le grantee agency, the
              Pennsylvania I-ledical Society.

                    Since there seems to have      been  much  change  qiid  redirection   of   the
              program, reviewers had difficulty in assessing a reasonable fundin@ recommen-
              d,iti.on.  Individual projects were not reviewed.

                    Several options were considered by Coniriittee before deciding           oft  their
              recommendation:

                    I-)-  that the Rei,!ion-be funded at the present level with a consultation
              visit before next year's submission.

                    2)  that  the  Region  be  advised  to  review   and   strengthen   the   staff
              capability,  particularly  in  the  procrapi   planning   and   evaluation   area   and
              that a  site  visit  be  scheduled  later  to  review  the  Regi.orL's  proc,):ess  and
              determine whether further fundin- should be added to the progra-,,i,

                    3)  that the Region be given approximately $200,000, an amount
              comparable to the Region's request for previously approved but unfunded
              projects,,for the next year, but that no funds for new  rojects be approved
                                                                                p
              until a site visit is made to review the status of the progrclm.

                    4)  that the Reaion be site visited before any funds be approved
                                                                                   p 0
              for the Fiction, with the  exception  of  the  oncoi,ng  rc!ne-,.jal  r  ject  7,@6R.

                    This  last  option  was  decided  upon,  partly  in  order  to   give   ttie-Region
              any additioi-ial  funds  at  the  be-inning  of,  rather  Lli@in  later  in  the  year.
                                                  L>
   I is             In  light  of  the  present  fund-i.ag  stringenci.es,  t.lie  need  for  @ucli  urgency
              does not apply.
                                                                       r@MPS/GRTi 1/1.9/71





              c.-USQUEEIAI:,IiA VALIE@Y              -3-


              b,AT)'O@,IAL ADVISO-@JY COIZTCIL      !,i 'L?@1971@
                                                                                      "i7E-ETZ-'Fi c I dto
              Covii-icil. concurred w;th tl-ie Coviiriittee's re  't  lia@     1   V). fi
              de-tei.-inin@- -a FLin(linE@, level for the comin- year and to assess t'Lic Pegi.on's
              progress since tl-ie l,ast site visq  -t.  Council di(.] Disprove rene,@?,i] of
              Project @'6R, Coronary Care I\Iurse Training at tti(-, Geisii-igei7            Center,
              as requested and siipT)ort for Proj(?ct iA25, Coronsry Core Niirse Trbininc,
              at the Al.toone Hospital for one year.













































                                                                               cP-,B/2/22/71,





                                                              (A Privile@,e(I  Communication)-



                                   STZIMNRY OF REVIEI@7 AND CONCLUSION OF
                                        APRII, 1971 REVIEIL CO@Ti',IITTEE

                               SUSQUEMkNiNA, VliLLEY REGIONAL IIEI)ICAT, PROG.@L
                                            Rl,i 00059    5/71


                           FOR CONSIDERATION BY IFAY 1971 ADVISORY     COUNCIL


               RECO@t@I.ENDATION: The Committee recommended that  R@'4!'S  provide  $100,000
                                 additional  funding  to  Susquehanna  Valley  M4P  with  no
               specific advice as to its  use.  Hoi,@ever,  the  Region  was  not  approved
               for  developmental  component  funding  as  such.  The  application   (submitted
               in November 1970 and deferred  by  February  1971  Council  for  a  site  visit)
               requests:  1)  the  activation  of  four  Council  approved  but  unfunded
               activities, 2) the  renewal  of  one  activity,  3)  the  implementation  of
               seven new projects and a developmental component.

               r@i  @u@:  Committee recalled that a site visit had been held as a result
                          of February Council's request, in order to determine a funding
               level for the coming year  and  to  assess  the  Regionts  progress  since  the
               last site visit.  Review Committee and Council at their last meetin-s had
               difficulty in  evaluating  the  application  because  the  Region  appeared  to
               be undergoing several  major  changes  and.neither  group  had  a  member  with
               recent.on-site  knowledge  of  the  Region.  Because  the  application   showed
               evidence  of  continuing  difficulties  in  leadership,  regional   planning
               and relationships with  ttie-medical  school,  a  site  visit  was  considered
               necessary. The  findings  of  the  site  visit  to  the  Susquehanna  Valley
               Region on M6rch 25, 1971, were reported to Comnittee.  The visitors
               outlined the strengths  and  weaknesses  of  this  Region  and  described  the
               progress since the visit in February 1970.

               The excellent grass roots  involvement  of  physicians  in  each  of  the  four
               Areas continues to'be  a  major  strength  of  the  Region.  The  site  visitors
               were impressed with  the  interest  of  providers  in  small  communities  in
               BIIP as a  mechanism  for  improving  patient  care.  The  organizational  plan,
               iiliich includes area  committees,  categorical.  councils,  an  executive
               committee, as well as the @kG,, appeared workable.  Young physician-
               chairmen of the  Councils  liave.given  much  assistance  to  the  Core  staff
               efforts.  Core, whil.e completely la     lins  made  some  major  contributions
                                                     Ys
               in program planning. It -Ls also x,2orking with  CIIP  in  some  joint  program
               efforts. The  early  emphasis  on  coronary  care  seems  to  have  broadened
               as evidenced by proposals in areas such as home health care, comprehensive
               health care centers, and cancer education.
               Despite  these  stron-  points,  there  are  overriding  weaknesses  which
                                    C)
               discouraged  both  site  visitors  and  Committee  members.  The  most  serious
               problem is the lack  of  stron-  direction  fresh  any  quarter.  Neither  the
                                              0
               Coordinator nor  any  one  on  Core  staff  provides  dynamic  leadership.
               The grantee agency,  the  Pennsylvania  Medical@  Society,  is  not  offering
     0         strong support to the program.     '@,lliile ti-ie ML I'P has tender-,] to function as
               la subordinate of the PL"IS,, the site visitors learned tilat the  firant(,e
                                                                                   C>






             SUSQUEIIANNA VALLEY W@IP           -2-                   RM 00059 5/71

             became so by default, not by any commitment to   the program.  The  Dean
             of t'ne new medical school at Hershey has been unable to bolster the KIP,
             because of both his urgent and immediate concerns  with  starting  the
             medical school and the lack of anyone on Cote staff  with  the  professional
             background to require better commitment from him.

             The Regional Advisory Group has been weak and reactive  to  the  grantee
             organization, to area demands and to national  priorities  and  review
             decisions. At the same time, it has not provided  much  support  to  Core,
             possibly because of the lack of medical leadership  on  Core  staff.  In
             fast when informed by RIIPS that available funds were  only  $24,313  more
             then the current Core budget, the PAC had considered  a  severe  cut-back
             in Core staff funding.  Strengths in the leadership in categorical Councils
             have not been built in to the RAG.


             While some RAC members present at the site vi sit seemed to  reassess  their
             evaluation of Core worthiness, the site visitors also Pattern tc@(I to
                                                                          p
             alleviate the untenable fbndina situation imposed by IOIPS  by  recommending
             that the Region receive some additional support  ($100,000)  to  preserve
             the very life of this RMP. The visitors hoped  that  such  an'amount  wou
             preclude expenditure of funds for such projetts as the Automated Computer-
             Assisted Analyses of the EEG, whicl@i seemed esoteric and out of line with
             the Region's more pressing health needs.  The $100,000 should enable the
             Region to initiate some worthwhile project activities and give the   RMP
             SOM6- visibility in the Region.

             Committee concurred with the site visitors reservations about the viability
             of the SVIL'AP as a Regional lledical Program. There was disagreement  among
             its members about what course to pursue in light of  the  problems  outlined
             above. Several members ques'tionned the desirability  of  investing  further
             support when conditions necessary for improvement did not  seem  in  the
             of f inc,, .

             Other members, hoige ver, believed that the Region had enough promise in its
             Core staff and community participation to warrant a chance  to  develop  a
             program.  In concert with the site visitors conclusions, Committee
             recommended that the Reoion should be informed that national reviewers had
             serious reservations about the future of the Program and  given  a  year
             and some additional support ($100,000) to strengthen  its  leadership  and
             produce a regional plan. The Region should also  be  informed  that  careful
             study will be made of the process by which the Region determines its
             allocation of funds and sets its proorain direction, and that medical
             leadership on Core staff is considered essential    Committee  con  u  e
             their discussion with the recommendation that both  a  strong  message
             from the Director, Pl@iPS, regarding Commitlee's hopes and  reservations
             about the Region and assistance from R@IPS staff accompany the  feedback  of
             their other concerns. The developmental component  request  as  such  was
             disapproved because of the weaknesses in the  decision-malting  structure.

             NOTE:  There were five dissenting,-votes.
                                                               ItMPS/CRB
                                                               4/211/71





                          DEPAR'I -.,ENT OF t-',  LTH, EDLICA7rlO;'4, ;@@,!D WL-.1 FARE
                                         PUi3L)C H17ALT14 SERVICE
                           HEALTI-I SERVICES A14D TAENTA'L- tiEAI-']'H ADMINiCI'RAT'.ON


       Dek.,  April 2, i971


      Subjeci.. Short Summary of Susquehanna Valley PJIP Site VI-sit Findings, March 25, 1971

              Directo
              Regional-led@tal Programs Service
              THROUGH.  Acting Deputy Director
                        Regional. Medical Programs Service


              The ,;-ite visit team consisted of:

                   J. Warr&n Petry, Ph.D., Dean, School. of  Health  Related  Professions
                                            State UniverF,,i-ty of New York at Buffalo
                   Bland W. Cannon, M oD., Council member
                   Manu Chatteriee, M.D., Coordinator,  Maine  Regional  Medical  Program
                   Sarah J. Silsbee, Chief, Grants Review Branch, Pd@TS
                   James Smith, Operations Officer,  Regional  Development  Branch,  RMPS
                   Clyde Couch-aan, Regional Office Representative, DHEW Region III, RMPS
                   Carol M. Lars6n, Allied Health Speci  dlist, Continuing  Education  and
                                            Training, Branch, RMPS

              the ite visit was held on March 25 as A  one-day  meeting  in  Camp  Hill,
              P&nnsvlvania.  The visit  resulted from Council.'s decision to defer action
              on the Regio@s request for additional funds including developmental
              funding.  The Council felt that it could not make a determination of
              the Region s progress in decision-making,  planning  or  priorities  until
              an on-gite visit was made.

              Background  This Region has had two site  visit  teams  studying  it.  Both
              site visit reports indicate a concern about where the focus lies on
              d6cision-making, planning and priorities.  Very early in its development,
              the Region developed A subarea organization with  staff  assigned  to  help
              area committees develop priorities in-- the categorical  areas.  All  site
              visit teams have reported an unusual deareo of  interest  among  the  pro@
              videts that Rrew out of this development.  At the same time  the site
              visitors noted a lack of overall regional- pl-anni.ng which.had the  areas
              wor ing out of context of a regional plan.  The 1970 site visit found
                at a council framework had been developed  around  the  categorical  areas
              And continuing education which was serving as a vehicle for regional
              planning in the categorical area.  However, the overall. priorities of
              the Region and the goals for the program as a  whole  were  still  unclear.
              Both site visit teams reported a lack of  understanding  about  the  contri"
              b7.iti. of the grantee agency; the medical  society,  the  Regional  Advisory
              Group and the medical school to program development.








            Page 2   Director, RNPS

            Since this Region began, there has not been a  physician  or  provider
            expertise on the core staff. The  Council  development  resulted  from
            recommendations of the first site visit team and  last  yeat's  team
            recommended that a faculty member from the Hershey lqedical  Center  be
            added to the staff to provide a bridge to  the  provider  community-

            The Region's proposed projects have seemed to be a  series  uP  disparate
            activities unrelated to one another or to an overall.plan.  The
            ap licati6n deferred by Council included two expensive co  uter projects
              p                                                        MP
            dealing with EKG and EEG,techniques. The  review  process  that  forwards
            this type of activity at this point in time was of  serious  concern  to
            the 1971 Site Visit Team.


            Findings of the 1971 Site Visit Tean,,: The site visitors came  away  wit
            ambivalent reactions to the Regional Medical  Program  in  Susquehanna
            Valley. Qu6stio'ns remain regarding the effect of  the  grantee  agency,
            the effect of the coinpletel lay core staff and the effect of  the  noia-
                                        y
            involvement of the medical school on the program.-  In  addition,  the
            Regio al. Advisory Group itself does not seem to have  a,clear  program
            direction in mind.

            Despite this, the site visitors were impressed with the interest
            generated by providers in small communities that  the  Regional  Medical
            Program could serve their needs in improving  patient  care.  -These
            needs have been perceived in a categorical framework because the
            Region believes the original intention of Public Law 89-235 represented
            the parameters in which they could plan. The core  staff  has  done  a
            good job in promoting this interest.

           .The grantee agency, the medical society, 18  not  providing  leadership
            or domination to the program in a direct fashion.  In fact, the
            representative of the board stated to the site visit  team  that  the
            medical society had become the  grantee  by  default.  There had  been
            some interest in having the Hershey Medical  Center  be  the  grantee
            but it was unable to take on the job. --The grantee  organization  takes
            its responsibilities for setting up  the  fiscal  procedures and  the
            staffing pattern very seriously, and has involved  a  management  group
            to come in and lay out the organization staffing, the  functions  of  the
            Regi6 al Advisory Group, the grantee and the  core  staff.  This  has
           @been carefully thought through and is quite clearly worked out.

            The core staff is completely lay and looks  to Council members  as  their
            resource for provider expertise. The team  was  quite  impressed  with
            the amount of time and effort the Council members  have  given  to.this
            a pect of the program. The Council chairmen as  a  group  were  young
              ysi6ians with very good qualifications in  their  individual  fields
            but t ey worked as requested by the core staff.








             Page 3   Director, RNPS
            @'Furthermore, the council chairmen are involved primarily  in  vertical
             plannin in limited areas, not horizoiatAl  latning  in  overall  program.
                    9                                   p
             The team was impressed with what the core staff  has  accomplished  while
             working under,the severe handicap of token support from  the  grantee  and
             the RAG.  The core staff simply does not have the composition -
             specifically, a physician - to demand commitment from  the  grantee,  the
             medical tenter or the RAG. There was.some  indication  that  the  core  staff
             does not feel the need for a@physician to serve in this capacity.
             Following    on the 1970 site visit  recommendations,  representatives  of
                       UP
             the grantee organization (but not the coordinator)  talked  with  Hershey
             Medical Center Dean about the assignment of-a  faculty  member  half-time
             to the Regional Medical Program. The Dean was  unable  to  provide  the
             faculty time; however, core staff indicated that individual faculty
             members were participating in council activities,  particularly  in  the
             Education and Manpoi@7er Council.,
             During this site visit, the team requested from  the  Dean-a  clear
             statement of commitment to the R@  from  the  Medical  Center.  The
             commitment was not forthcoming; instead the  Dean  aired  his  frustration
             about delays in faculty recruitment, lack of financial support from
             Pennsylvania State University, the parent institution,  lack  of  clear
             authority to serve as the University agent for continuing education
             (at present Jefferson Medical College has  the  University  contract  for
             continuing education for physicians  while'the  University  retains
             responsibility for continuing education for  all  Allied  health  personnel).
              n answer to direct questions, the Dean declared no  concern  about  the
             medical society as grantee or about-the  schools  under  representation
             on the RAG and lack of influence in the  overall  Program.  Clearly,  the
             Dean's immediate concerns preclude much thought  about  the  Susquehanna
             Vall e  P&[P.
                  y
             The Regional Adviso,ty-Group has not been a positive sourc e of  leadership
             or direction; kather, it has been reactive -@. to the grantee  organization
             to area demands, to national review  decisions.and  to  national.priorities
             as opposed to Public Law 89"239 priorities.  Except  for  several  members-
             at-large, the RAG membership is determined by  area  committees  or
             org izatiorLs which make up the.coalition of interests in  the  PM  .  The
             council chairmen serve the RAG in a technical review  capacity,  but  are
             not members.

             The team learned that the Regional Advisory Group was considering 9 severe
             cut-ba& in co-re funding, in order to fund  several  projects.  The  RAG
             apparently perceives tore expenditures  as  overhead  and  project  expendi
             tures as "program.11 Thus, when informed by RNPS  that  the  funds  available
             would be only $499,513, or $24,313 more than the cu  rr&nt coke  budget,  the
             RAG anted to cut the "overhead." The site  visitors  weke  able  to  elicit
             s ff,iti6nt information About core activities which had resulted in program








             Page 4   Director, 'P@IPS

                                             -ts, that several  P@ members were
             ,development, but not R@ proje.@
             reassessing their evaluation of core worthiness. The,R.AC- i-7as.-to  decide
             on new budget allocations on April 1.

             Recommendations of the Site Visit Team:


             1.  That RMPS@.Provide $100,000 additional funding to Susquehanna.    Valley
             RMP with no stipulation as to how the funds should. be ut@i-lized.    The
             RMPS.level does not take into consideration the fact that the Region's
             commitment included very little  project  funds.  This  Region  is  faced
             with an untenable funding situation imposed by the l@S decision.

             2. That the Region be  informed  that  national  reviewers  have  serious
             reservations about its viability  as  a  Regional  Medital  Prograt,  the
             lack of cleat commitment to, or  interest  in,:an  effective  program  by
             the grantee, the medical center and the FAG;  the  capacity  of  the  Region
             to set priorities and to negotiate local area demands, as evidenced by
             the projects proposed..

             3.  That the Region be informed that core staff is functioning well
             without much help from key groups.  Its community participation and
             involvement are unique and impressive.  These two strengths are
             responsibile for the additional funding recommended.

             4.  That the Region be informed that the national reviewers recommend
             ,additional funding at this time to give the Region  a  chance  to  chart
             its own@destiwy without dependence on  national  review  actions,  and  that
             the national reviewers believe a physician  on  core  staff  would  serve
             the Region:well.

             5.  That the Region be informed that careful study will be made of the
             Processes by which the Region  determines  its  allocation@of  funds  and
             sets it program direction.




                   J. Silsbee
             Chief
               ants Review Branch




                                                              A Privileged Communication)



                                    SITE VISIT REPORT
                      SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM
                                      March 25, 1971



            SITE VISITORS
          -J. Warren Perry, Ph.D., Chairman, Dean, School of  Health  Related
              Professions, State University of New York at Buffalo, New  York

            tiand W. Cannon, M.D., Council member, Memphis, Tennessee
            Manu Chatterjee, M.D., Program Coordinator, Maine Regional Medica
              Prbgrqm, Augusta, Maine

            REGIONAL MEDICAL PROGRAMS SERVICE STAFF

            Mrs. Sarah J. Silsbee, Chief, Grants Review Branch
            Mr. James Smith, Operations Officer, Regional Development  Branch
            Mr. Clyde Couchman, Regional Office Repres&ntative            I .
            Miss Carol M. Larson, Allied Health Specialist, Continuing Education Branch

            SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM

            Richard,B. McKenzie, Director
            James E. Smith, Assistant Director for Program Development
            John D. Hoffman, Assistant Director for Technical Services
            Richard E. Wright, Field Service'Coordinator
            Franklin E. Williams, Educational Activities Coordinator
            James Patterson, Grants Management Coordinator
            Robert M. Fisher, Communications Coordinator
            Ellsworth R. Browneller, M.D., Director of Governmental  Affairs,
              Geisinger Medical Center, former Secretary of Health for the
              Commonwealth of Pennsylvania, Chairman of the RAG.
            George C. Williams, ESQ3- Wellsboro attorney, Vice-Chairman of RAG
              and Chairman of its Planning Committee, Community hospital board member
            John F. Rineman, Executive Director and-Treasurer of the Pennsylvania
              Medical Society, grantee for the-SVRMP,, RAG Treasurer
            John H. Harris, Sr., M.D., Harrisburg radiologist, RAG  Executive
              Committee and Chairman of the Special Board Committe6.for SVRNP
              of the Pennsylvania Medical Society
            Aaron H. Claster, Lock Haven businessman, RAG Executive Committee, a
              community hospital board member, active in CHP activities
            J. Mostyn Davis, M.D., Shamokin family practitioner, RAG Executive
              Committee, the Northeastern Area Executive Committee
            James C. Kirk, Administrator of Pottsville-Hospital, RAG Executive
              Committee, Northeastern Area Executive Committee, Past President
              of the Hospital Association of Pennsylvania






           SUSQUEHANNA VALLEY RNP                                RM 00059

           Charles A. 'Laubach, Jr., M.D., Chief of the Cardiovascular and
             Pulmonary Disease Section, Geisinger Medical Center, Chairman of
             the SVREP Council on Heart Disease, active in the Northeastern
             Area Committee, President of the Pennsylvania Heart  Association
           Bernard F. Carr, Superintendent of Altoona Hospital, RAG  Planning
             Committee and the Appalachian-Highland Area Committee, President-
             elect of the Hospital Association of Pennsylvania
           William.Sc@irmer, Assistant Administrator, Harrisburg Hospital,
             Treasurer of the Board of the Hamilton Health Center project, now
             funded from 314(e) funds
           George T. Harrell, Jr., M.D., Dean-and Director, The Milton S. Hershey
             Medical Center, The Pennsylvania State University, Member of the RAG,
             and of the Special Board Committee for SVRMP of the Pennsylvania
             Medical Society
           William H. Jeffreys, M.D., Director of the Department of Neurology
             and Psychiatry, Geisinger Medical Center, Chairman of the  SVRNP
             Council on Stroke  -
           Roland A. Loeb, M.D., Lancaster cytologist, Chairman of the  SVRMP
             Council on Cancer
           David D. Pearson, Ph.D., Professor of Biology, Bucknell University,
             Chairman of the Northeastern Area Committee.
           Nikitas J. Zervanos, M.D., Director of Community Medicine, Lancaster
             General Hospital, Member of the SVREP Council on Facilities  and
             Services, project director of the proposed Family and  Community
             Medicine Program in present application.





                                                                       DRAFT
                                                              (A Privileged Coumunication)


                                     SITE VISIT REPORT
                       SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM
                                       March 25, 1971




            Structure of Site Visit

            This was a one-day meeting, designed to assess the  Region's  progress
            in setting goals and priorities, in resolving  differing  expectations
            among the grantee organization, the RAG, the area committees  and  the
            core staff, and in enlisting involvement from the Hershey Medical
            Center.  The site visit agenda, as originally developed by the
            coordinator, called for an early session with the core staff alone,
            followed by a long session with about seventeen  representatives  from
            the grantee organization, the RAG, area committees. the  medical  center
            and Councils. RNPS staff asked that the larger group  be  divided  into
            functional lines for part of the day; instead, smaller groups of
            cross-8ectional representatives were scheduled for the morning and
            afternoon sessions.  The PAG chairman and vice-chairman, as well'as
            individual members from Councils and area committees-were present
            during both sessions.  The Hershey Medical Center dean was present
            for a short time during the afternoon, but was unable to stay  for  the
            feedback session at the end of the day.  The feedback session was
            taped for later distribution. With only one day, the  site  visit  team
            wasted no time in getting directly to the point of their visit; so
            with the cross-representative participation from the Region,  the  team's
            persistent probing reached all levels of planning  and  decision-making
            at the same time. Initially startled and defensive by  the  direct  line
            of questioning, th@ participants then opened up w'lth frank,  thoughtful
            responses.

            The Issues as Posed by the Site Visit Team
            "What has your Regional Medical Program accomplished and what  does  it
            hope to accomplish in the next few years? You seem to  have  amassed  the
            necessary ingredients for a Regional Medical Program, but  someth  g  is
            missing and we can't see the Program emerging. Your  Region  has  several
            unique features. You have the State Medical Society  as  the  grantee,-is
            this a problem in your development. Your Region has a  core  staff  devoid
            of 'provider' expertise. What have you done to fill  that  gap?  Your  RAG
            seems-to be a coalition of representatives from organizations, is  this  a
            factor?  Your medical center does not seem to be involved, except for the
            Dean's membership on the RAG; has this impeded your progress?  We realize
            there are reasons for these unique features  and we accept them.  But show
            us what you have done, where you want thisprogram to go, and why you feel
            you need additional RNP dollars from the limited funds available."  Later,
            to the Medical Center Dean: "Why isn't the.Medical  Center  more  involved
            in the PM, for example, in continuing education? Is  it  the  grantee,  is
            lt'the lack of representation on the RAG ,is it the core staff?"





           SUSQUEHANNA VALLEY                                       RM 00059

           Immediate Responses to the Issues

           From the grantee representative s: The State Medical Society  became  the
           grantee by default; the Hershey Medical Center couldn't take on  the  job.   ------
           We have employed management consultants to help us map  out  the'organization,
           the core salary structure, the functions of the RAG,  representation  on
           the RAG, composition of the Councils and the Planning Committee.  We
           have followed every suggestion made by national reviewers; last  year  we
           asked the Hershey Medical Center to appoint a faculty  member  half-time
           to serve on the core staff, as suggested by the site visit team,  but  the
           Dean was unable to assign any one.

           From RAG representatives: -When is Washington going to give us  some  clear
           signals on what it wants. Originally, we planned to  make  coronary  care
           improvement our major priority, but the National Advisory Council  said  we
           had to limit our funding to a few pilot areas. We  need  project  money.
           The Area Committees, cited previously as our strength, are  showing  waning
           interest because Washington's changing signals preclude funding  of  their
           project proposals.

           From the core staff: We have  been  succe'ssful in getting help from  individual
           members of the Hershey Medical Center faculty, in planning  the  physicians
           assistant forum, and in the Manpower and Education  Council.  We  get  medical
           guidance from the Council chairmen. We have  also  worked  in  non-categorical
           program areas, were the resources used in developing the  Hamilton  Health
           Center proposals which has been recently funded by 314(e) funds.
           From the Council representatives: We have developed plans  and  priorities
           in the categorical disease areas. With a  unique  combination  of  specialists
           from the clinics and hospitals and area representatives, we  have  developed
           feasibility studies prior to project proposals. In the  heart  area,  we
           have developed an evaluation,approach that involves not only  the  hospitals
           which received RNP funds but those that hoped to, but had to  find  their  own
           financial resources.

           From the Area Representatives: Core staff have helped  us  develop  project
           proposals.  We need money for their implementation..
           From the Medical Center Dean: The State Medical Society has  always  supported
           the medical center; we couldn't develop the center and serve  as  the  grantee
           for the Regional Medical Program simultaneously, although later, we  may  be
           interested. We are using RNP funds for the library  project  which  provides
           literature searches and reprints to physicians, the  service  seems  well
           accepted.  We may be able to develop some cassettes for educational purposes.
           We are glad to make auditorium.facilities available  for  RMP  activities.  My
           faculty is spread too thin now and could not serve on the RAG, perhaps later.
           I have no authority from Pennsylvania State University to develop a continuing
           education program.for physicians, Jefferson-Medical College has a contract for
           that, the University has responsibility in the allied health education field.
           Fatulty recruitment is behind schedule; financial support from  the  State
           -University has never materialized.






            SUSQUEHANNA VALLEY                                     RM 00059

            General Findings of the Site Visit Team

            1. The Region is making some progress toward  developing  its  goals,
            objectives and priorities, although it has a long way to  go  before
            they are clearly stated, specific, related to national goals and
            generally-understood and accepted throughout the  Region.  The  RAG's
            new Planning Committee is tackling the problem with core staff
            assistance, and with subarea representation built into the RAG,
            the Planning Group's deliberations could be  disseminated  throughout
            the Region. The categorical Councils and the  Councils  on  Manpower
            and Education and Facilities and Services are other possible.strengths,
            composed as they are of young specialists and area practitioners;
            however,, the Council representatives need to be utilized in  broader
            program planning; at the present time, their skills are  limited  to
            vertical planning in a specific area.

            With this Region's strong community involvement of  private  practioners
            interested in patient care, the transition from  categorical  emphasis
            to a more comprehensive approach may not be as difficult a s in  Regions
            which have not reached the physician at the community level.  The subarea
            categorical committees may be a barrier to this transition.  The team
            heard evidence regarding one areals cancer planning that  left  grave
            doubts about the present method of decision-making.  One area, having
            decided to develop a mobil& cancer detection proposal for  some  unclear
            reasons, was now regionalizing the plan, after consultation  with  the
            staff and the Cancer Council.

            The use of data as an aid to planning objectives and priorities has not
            been recognized, although cote staff is seeking consultation from the
            medical center for'some data studies.
            2. The organizational effectiveness is spotty.  -The  coordinator  and
            the core staff have been performing herculean tasks with  very  little
            positive direction or support. The team was  relatively  effective  in
            demonstrating that core staff activities had resulted in program
            development. The RAG and area committees  were  apparently  measuring
            program progress by project funding and considering the  core  staff
            funds as "overhead."

            However, the coordinator does not have the background,  experience  or
            stature to command the commitment of the grantee organization,  the  RAG
            or the medical center. The cote staff needs tolave  medical  liaison  to
            carry on these functions.  The site visit team felt that several of the
            Council chairmen could serve in this capacity, if given the responsibility
            and authority.  The tore staff also lacks representation from the allied
            health professions.  In fact, nursing and other allied health influences
            are scarce throughout the various levels of decision-making.
            -T-he grantee organization has set up adequate procedures for managing the
            funds, providing staff services, etc. Throughthe help  of  a  management






            SUSQUEHANNA VALLEY RMP              -4-               RM 00059

            consultant fund, the functions of the grantee and the RAG have been
            carefully delineated.  The grantee has not provided domination or
            direction of the program; nor, has it sought leadership from  elsewhere.

            The RAG has not provided leadership or direction; rather, it has been
            reactive - to-the grantee organization, to area demands, to  national
            review decisions and to national priorities as opposed to Public  Law
            89-239 priorities.  Except for several members-at-large, the RAG
            membership is determined by area committees or organizations which
            make up the coalition of interests in the RNP.. The council  chairmen
            serve the RAG in a technical review capacity, but are not members.

            The subregionalization efforts have been successful in enlisting local
            representatives in project planning. In the absence of  regional  goals,
            the subarea demands have been hard@to arbitrate. Also,  the  subregional
            representatives seemed relatively unaware of PM fiscal constraints
            on-the national level, the RAG reflects this same lack of  communication.
            Nevertheless, the subregional development of this Program is a  strength
            that can be utilized in program development.

            3.  The involvement of regional resources is spotty.  The medical
            profession is involved, at all levels.; The nursing and allied health
            professions are involved in projects and subarea planning, not at the
            regional level.  The community hospitals are involved to some extent,
            board members as well as physicians. The voluntary and  official  health
            agencies are involved on the RAG and in the subareas to a certain  extent.
            The medical school is little involved. This is a  real  problem.  The
            CHP development in this Region is just underway, and members of the  RAG
            and Councils expressed-concern that their staffs would duplicate  REP
            core staff. The team suggested that rather await signals from  Washington,
            efforts be made locally to coordinate, complement or assimilate the  staff
            efforts of the two organizations. The team did not get  any  feeling  for
            involvement of consumers or political representatives. The  RAG  chairman
            was formerly State Commissioner of Health.
            4.  As noted before, the Region has not depended on a data base for
            planning or evaluation.
            5. Core staff has done as well, or better than could  be  expected.  They
            have developed a health center which is funded through 314(e)  funds.
            They have developed feasibility studies with the help of Council  members,
            and they have looked for other sources of funding for ongoing  activities.
            Neither the operational projects funded nor the ones proposed are exciting.'
            The coronary training projects at Geisinger and Altoona would appear to be
            good investments and needed.  An evaluation study in coronary care has
            evolved to encompass many hospitals throughout the Region.  The
            computerized EKG and EEG project pro'osals are typical examples of  this
                                                p
            -Region's lack of understanding about national funding priorities.






           SUSQUEHANNA VALLEY RNP               5-              RM 00059

           6.  It is not surprising that evaluation has barely begun, but it
           has been started in the coronary care field.

           Recommendations of the Site Visit Team


           1.  That RNPS provide $100,000 additional funding to Susquehanna
           Valley RNP with no stipulation as to how the funds should be utilized.
           The RMPS level does not take into consideration the fact that the
           Region's commitment included very l'ittle project funds. This  Region
           is faced with an untenable funding situation imposed by the PMS
           decision.

           2.  That the Region be informed-that national reviewers have  serious
           reservations about its viability as a Regional Medical Program: the
           lack of clear commitment to, or interest in, an effective program  by
           the grantee, the medical center and the RAG; the capacity of the Region
           to set priorities and to negotiate local Area demands, as evidenced by
           the projects proposed.

           3. That the Region be informed of the necessity to have  a  physician
           serve a liaison leadership-role with the medical society, the medical
           center and RAG.

           4.  That the Region be informed that core staff is functioning well
           without much help from key groups.  Its community participation and
           involvement are unique and impressive.  These two strengths are
           responsible for the additional funding recommended.

           5.  That the Region be informed that the national reviewers recommend
           additional funding at this time to give the Region a chance to  chart
           its own destiny without dependence on national review actions.

           6.  That the Region be informed that careful study will be made of the
           processes by which the Region determines its allocation of funds  and
           sets it program direction.
















                                                        RMPS/GRB









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


           TRI-STATE REGIONAL 14EDICAL  PROGRAM                   RM 00062  5/71
           Medical Care and Education Foundation Inc.             April 1971 Review Co    ttee
           Two Center Plaza, Room 400
           Boston, Massachusetts  02108




           Requested      01                    02                   03
           Program
           Period    6/l/71-5/31/72       6/l/72-5/31/73       6/l/73-5/31/74     Total
           Direct Costs   $463,292            $368,595             $381,513     $1,213,400
           Indirect Costs   -0-                  -0-                 -0-            -0-


           Total          $463,292            $368,595             $381,513     $1,213,400

           History:  In November 1970, Council reviewed the Region's total program and
                     its Triennial application, and concurred with the favorable report
           of an October 1970 site visit.  Council concluded that the Region had devel-
           oped the capacity for self-determination; had set realistic, timely and accep-
           table goals and objectives; and had adequate docision-making processes as
           well as management and evaluation capabilities.  Although  the Council approved
           level of funding for the Region's Triennial application during the next three
           years is $2,261,685, $2,015,591 and $2,043,035, RMPS fiscal restraints will
           only permit $1,722,474 funding and commitment for these periods.
           Present Avplication:. The application contains one kidney disease project,
                                 which is also to be reviewed by an RMPS Ad Hoc Panel on
           Renal Disease on April 14-15,  1970.
           Project #1-  New England Regional Kidney Program
           Submitted by the Tri-State nO, this three-year project proposes to establish
           the New England Regional Kidney,Program  (NERKPRO) to assure that no person
           will die of kidney failure because of a lack of funds, or lack of a plan to be
           treated on knowledge of what is available.  The proposal is in three parts.
           Part I - A general introduction documenting need and resources.
           As a result of a recent series of meetings sponsored by the Tri-State RMP, a
           group of leading nephrologists and other interested persons joined to develop
           NERKPRO.  (See Apendix X:  Minutes of NERKPRO Meetings - Durham, New Hampshire;
           pp..,107-138).  There is general agreement that NERKPRO must meet several basic





           TRI-STATE RIMP                           2 -                    RM 00062  5/71
           needs:  1) a present need for more cadaver organs; 2) the need for larger
           pools of prospective donors and prospective recipients; 3) professional
           training  prog.rams are needed for physicians, nurses and technicians in the
           fields of hemodialysis, organ harvesting, organ transplantation, and tissue
           typing.
           Boston and New Raven are major transplant  centers,  and  others  are  in  the  pro-
           cess of being developed in the region.  Transplant centers are also centers
           for professional education and training in kidney disease.  In addition,
           Boston is the location of  the  Interhospital  Organ  Bank  (IOB),  a  clearinghouse
           for matching cadaver organs with potential recipients.
                             NEW ENGIAND FACILITIES FOR END-STAGE KIDNEY DISEASE

           .Central Support:                 Interhospital Organ Bank
                                             Massachusetts General Hospital
                                            .Boston, Massachusetts


           Dialysis Units:


                   Boston
                                                                           Maine


           Boston City Hospital                              Maine Medical Center, Portland
           Lemuel Shattuck Hospital
           Massachusetts General Hospital
                                                                           Connecticut
           Peter Bent Brigham Hospital
           University Hospital
                                                             Yale-New Haven  Hosp.,  New  Haven
           Veterans Administration Hospital                  Hartford Hospital, Hartford
           St. Elizabeth's Hospital                          Veterans Administration Hosp.,
                Other Massachusetts                                 West Haven
                                                             Bridgeport  Hospital,   Bridgeport
                                                             St.  vincent's  Boap.,  Bridgeport
           Babcock Street Uniti Brookline                    Danbury Hospital, Danbury
           Lakeville Hospital, Lakeville                     Waterbury Hospital, Waterbury
           North Shore Regional Dialysis Unit., Beverly      Hospital of St. Raphael,
           Springfield Hospital, Springfield                         New Raven
           St. Joseph's Hospital, Lowell
           Worcester Memorial Hospital, Worcester

           Transplant Centers:


                 Operative

           Boston City Hospital
               Harvard and B.U. Services
           Massachusetts General Hospital
           Peter Bent Brigham Hospital
           University Hospital
           Vet6ran Administration Hospital


           Yale-New Haven Hospital





           TRI-STATE RMP                       - 3 -                 RM 00062  5/71

           Part 2 - An application for funds to finance regionalization
                    of the operations of the Inter-hospital Orpan Bank.

           Reoism-ni'zliti,o-u, -6f,--,-the IOB is a major component in the development of the,
           NERKMO program. The 'bank", a  non-profit  organization,  is  actually  a  center
           for information, expertise, the performance of technical functions (tissue
           t"ing), and administration,of organ  allocation.  Major  functions  of  the  IOB
           include: 1) Education and information  efforts,  primarily  with  physicians,  to
           encourage the "harvesting" of cadaver organs suitable for transplantation;
           2) Operation of a central office: (a) serving  as  a  communication  center  through
           which information an organ availability, suitability, and  demand  can  be  ex-
           charged, (b) maintenance of a central registry  of  persons  awaiting  transplant
           and of potential donors, and (c) administration of a system  forcT41td-fmiWin-g-the:
           allocation of cadaver organs available among  the  patients  awaiting  transplant,
           using information determined by central  serotyping  laboratory;  and  3)  operation
           of a central serotyping laboratory.
           The IOB is currently supported under a contract from  the  Kidney  Disease  Contro
           Program, RMPS, and funds from the Massachusetts  Department  of  Health.  The  IOS
           has begun chargimgfees for serot"ing, and is negotiating with third party
           payers to make these and related costs reimbursable.  The  IOB  is  in  the  process
           of expanding the field of operation to serve the  entire  New  England  region.
           Financial assistance is needed to support the IOB during this transitional
           stage when:  <I) the 103 is expanding its physical capacities, geographic
           coverage, and training activities, (2) support  from  the  Kidney  Disease  Program,
           RMPS is being phased out, and (3) income from fee-for-tervicas  is  not  yet  suffi-
           cient to support these operations on a full or  regular  basis.  (Pages  47-53  of
           the application describe steps to be taken to  facilitate  expansion  of  the  103.)
           A total of approximately $166,000 is requested for the  first  year  support  of
           the IOB as follows: $128,289  personnel;  $22,524  supplies;  15,3  0  equipment*
           Part 3 - Describes the steps to be taken in developing  the  remainder  of  the
                    program components so that at the end of the  grant  period,  a  coor-
                    dinated re@ional program will exist.
           The development of the program will be administered by  George  L.  Bailey,  M.D.
           with the advice of=RVW,  its  Scientific  Advisory  CommittOe  and  other  com-
           mittees. In addition to the IOB, other program  elements  will  be  developed  as
           follows*.
                     Development of Programs and  Standard  Setting:  NERKPRO  through-'its
           Scientific Advisory and other committees will offer advice  to  any  group  con-
           templating development of a kidney program (Pages 28-29).
                     Professional Training-,  Is discussed on pages 29-35 of the application.
           The applicant notes that present RMPS guidelines exclude  the  support  of  ph*si-
           clans fellowships. If funding  becomes  available,  a  fellowship  training  program
           in nephrology or transplant surgery  would  be  implemented.  Support  is  requested
           for the training of: (1)  Dialysis  Nurses,  (2)  Transplant  Nurses,  (3)  Dialysis
           Technicians, and (4) Tissue Typing Technicians.




            TRI-STATE RMP                        - 4 -                    RM 00062  5/71
                                          (1)  Nurse  Consultants  in  Dialysis  and  Trans-
                 Continuing Education:
            plantation will be available for any program in the region to assist with
            specific problems, demonstrate new techniques to remote centers, and act as
            advisors to areas  starting  new  programs.  (2)  An  annual  two-day  workshop  on
            new developments in dialysis and transplantation will be held for nephrolo"
            gists, transplant surgeons, imunologistg, nurses, and technicians.  (3) Short
            (up to two weeks) individual training  courses  to  update  skills  will  be  spon-
            sored.
                 Organ  Procurement:  ia  and  Physician  Education:  As  presented  on   pages
            33-35, this would involve: (1)  Training  organ  harvesting  teams,  (2)  educating
            the general public to increase their  willingness  to  be  donors  and  recipients,
            and (3) increasing the awareness of  the  physician  in  general  practice  con-
            cerning the desirability and practicability of treating end-stage kidney Aiaease.
                 The Funding Desk (Pages-36-43):  This desk would serve three basic functions:
            (1) Serve as a clearinghouse for information concerning presently available
            sources of financing; (2)  collect data on third-.party payer experience     I  with
            reimbursement for kidney disease  and  other  catastrophic  conditions,  and  would
            develop proposals for.more systematic  funding  of  these  conditions;  (3)  under-
            take special investigations into  the  impact  of  prospective  changes  likely  to
            effect financing of end stage kidney disease over the next few years.
            Registry of NERKPRO (Pages 44-46)
            The registry functions would include:
                 1.  Maintenance of an up-to-date   registry  of  all  potential   cadaveric
                     transplant recipients  in  order  to  provide  the  necessary  information
                     for the equitable sharing of cadaver organs.
                 2.  Registration of  all  live  related  donor  transplants  for  purposes  of
                                         I
                     follow-up   on succeIso rate, funding profile, statistics, etc.
                 3.  Registration  of all  dialysis  patients  indicating  whether  center,,
                     satellite   or home; source of funding; location; etc.
                 4.  Registration  of every  physician,  nurse,  or  technician  trained  in
                     dialysis, transplantation or tissue typing in New England.
                 5.  Registration  of  every  dialysis  and  transplantation  facility  not  ng
                     their patient capacity, training capacity and costs.
            A  total of approximately $297,000 is requested for this part of NERXPRO (does
            not  include  IOB  costs)  as   follows:   $74,829-personnel;   $5,000-consultants;
            $7,360-furniture;  $16,000-travel;  $142,200-training and continuing education;
            $19,270-rent  and  telephone;  $11,020-postage  and   special   transportation;,and
            $21,500-computer tiwe and fees for harvesting organs.






          TRI-STATE RMP                       - 5 -                  RM 00062  5/71
          The Appendices of the application contain  copies'of 52 letters of support
          and participation; by-laws, rosters and other information for the IOB;
          Teaching Protocol for Twin-Coil Machine Dialysis; Funding of Renal Patients
          in New England; Minutes of NERKPRO meeting; and curriculum vitae of key
          personnel.



























                                                             RMPSIGRB  3/9/71




                                                       ,,(A  Privileged  Communication)




                             SUM.IARY OF REVIEW AND CONCLUSION OF
                                 APRIL 1971 REVIEW COMMITTEE


                             TRI-STATE REGIONAL MEDICAL PROGRAM
                                          RM 00062  5/71

                       FOR CONSIDERATION BY MAY 1971 ADVIS@Y COUNCIL



               RECOMMENDATION:  Deferral for a site visit

               Year                         Regilest             Recommended Funding

               Ist@                        $463,292                   -0-
               2nd                          368,595                   -0-
               3rd                          381,53.3                  -0-


               TOT                       $1,213,400                   -0

              @Dui ng its review, the Committee did,not have access   to  the  tecommenda-
               tion of the Ad Hoc Panel on Renal  Disease, since the  two groups met
               s    taneous v. From a program point  of  view  the  Committee  believed
               the@proposalx,arranted support.  The Panel  believed  further  technical
               eva nation by a site visit was warranted.

               Committee Program Critique:  The reviewers, includin  an individual
                                                                      9
               who@served as chairman of the October 1970 triennial review site
               vis t. were favorably impressed with the proposal. The Committee
               fo  d this to'be a well-thought out and well presented program, which

                   her, the reviewers believed that the RNP had the caDabilitv to
                     ut its plans as presented.  The Committee realized their
                a   able recommendation was subject to A satisfactory technical
                      by the Ad Hot Renal Panel.

               Panel Technica-- Cr   que:  . e  ane  s recommen
                       i      s    se
               a site v sit wa ba d on  the  following  concerns:  1)  There  w6re:gerious
               reservations as to whether the appropriate individuals within the six
               st  es had had ample -o portu-nity to review the proposal in  its  final
                                      p
               -Fo
                   ;to determine the degree of,collaboration and cooperation that would
               be  e4uiied; 2) The budget seemed extremely excessive;  3)  the  extent  of
               Pd  icipati.6n by the Board of Governors could not be clearly determined;
               and 4) Due to the magnitude of the  program,  further  detailed  evaluation
               of  ts many facets seemed warranted.
                D !Edud Lewis was::not present during the discussion of this
                apiication.
                @p

                                                            RMPS/GRB
                                                            4/21/71





                                 REGIONAL MEDICAL PROGRAMS SERVICE
                    SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION
                                     (A Privileged Communication)

            WESTERN PENNSYLVANIA REGIONAL                    RM 41-03 (AR-1-CD)  5/71
             MEDICAL PROGRAM                                April 1971 Review Committee
            501 Flannery Building
            3530 Forbes Avenue
            Pittsburgh,  Pennsylvania   15213

            PROGRAM COORDINATOR:  F.S. Cheever, M.D.
            PROGRAM DIRECTOR:  Robert R. Carpenter, M.D.

            This Region is currently funded at $1,248,391 (direct costs) for its second
            operational year ending June 30, 1971.  $226,350,of  this  amount  represents
            unspent first"year funds reauthorized as carryover into the second year.
            The Region currently receives indirect.costs of $272,633 which  is  21.8%  of
            the direct cost award.  It submits a triennial application that proposes:

                    I  A Developmental Component
                  !I   The continuation of Core.and 7 ongoing activities
                 III   The renewal of one activity for 2 additional years
                  IV   The implementation of 5 new activities, one of which is
                       a revised kidney disease proposal previously returned
                       for revision
                    V  A budget for the second and third  years  of  the  triennium
                       that requests growth funds for activities currently in the
                       planning stage but scheduled for later activation
            The Region requests $1,757,550 for its third operational year, $1,970,875
            for the fourth and $2,233,286 for the fifth year.  A breakout chart
          .Identifying the components for each.of the three years  follows  on  the  next
            page.
            This Region is to be site visited March 10-11, 1971.  Staff's preliminary
            review of the application has identified several issues for'.the,site team a
            consideration.  These are also covered briefly in this summary.

                                          FUNDING HISTORY

                                              Plannin?,

            Grant Year                      Period                  Funded (direct dosts)
               01                    I/l/67-3/31/68 (15 mos.)              $271,736
               02                    4/l/68-6/30/69 (15 mos.)               354$234

                                        Operational Program
               01                           7/l/69-6/30/70                  934,041
               02                           7/l/70-6/30/71                1$248,391

                  The Region has been advised that its funding  level  for  the  upcoming
   0              year must be held to $863,996 due  to  overall  budgetary  constraints.





                                                                                                                   RLC; 1 n\' Western Pennsylvania
                                                                                                                                                 Triennium
                                                           BREA,KOUT OF REQUFST               03         PERIOD


                                 OF
                                                                                  !APP@.ILT.14F'-jN-. 'AC'!"IVIT,@ES DIRECT        TN'ETRi7,,-r,      TCT"--
              Developmental                                                                          1100,000            ioo,oooi     21                    ooo

              junspecified Projects.
              r
                                                                                                                                                      899.1
              @CORE                               1      694,385                                                        694,385         204,740
              @#1 P          Faculty                    35,450                                                           35,450         8.715    1    44,165
                   egional
                                                                                                                         97,500         1 19
              !#2     Hypertension                      97,500                                                                               _5       138,695
                                                                                                                                86           67       172,053
                                                                                                                        118,4         53,5
              1#3 Coronary Nurses                        118,486

                                                                                                                                                      32,698
                                                                                                                         26,875-i       5,823
              i#4   ERr   Training                      26,875                                                                                -
                                                                                                                         50    ooo    230266          73,266
              :#7 Library System                        50,000
                                                                   1  143,445                                           143,445    1  68,889     i    212,334
              i#6R Nursing Home
              @#8 Laurel Rome Health Aides              75,000                                                           7.5,000,                     75,000
              ;!#9 Cancer Chemotherapy                  44,820                                                           44,820         7,933         52,753
                                                                                                                                                      37,424
              -#IO Early Coronary Care                                                                :37,424            37,424

                                                                                                       50.000            50.000       19-127          69.127
              ::#II  sickle   Cell

                                                                                                                               000    20.900          70.900
              1#12 Diabetes Mellitus                                                                   50.000
                                                                                                                                                      42,115
              :;#13 Pulmonary Disease                                                                                        -,115
                                                                                                                                                      192,050
                                                                                                   @192,050             192,050
              #14 Renal Disease




                                                                                                   !471,589         fj
                                                                               5                                        757,550    i    474,155  i2,231,705
                                       O'.AL           1,142,516        143,44


                                                                                                                0



                                                                                                                                              Western Pennsylvania
                                                                                                                                 CYCLE
                                                                  BREAKOUT OF REQUEST                   04             PERIOD


                                                                                            ipPEVIC;USLY          NE!4
              'IDT-7@@'@- !'FICATION OF                 I CON-Eiiul,\'C,   i                                                                       I
                                                                           iRENEWAL         :.kPPR/UNFUN.!ACTIVITIES
              C C','- O.@ 7 @; T                        @ACT'VITI.FS                                                                DIRECT         INDIRECT              TOTAL

                                 I                                                                                ioo,odo                             20
              'Developments                                                I                                                         100,000                 ooo         120,000
                                                                                                                                                       Not
              iUnsEecified       ProJects               I                                                         400,000            400,000       @pe@ified             400,000
                                                                                                                                     828,000       i     240,700         1,068,700
               CORE                                        828,000*




               #2


               #3


               #4


               #7

                                                                                                                                     146,337          72     333         218,670
               #6R                                                             146,337
                                                            180,000                                                                        80,000                        80,000
               #8

               #9                                            46.995                                                                        46,995          8,318         55,313

               #10



                                                                                                                                     60,000        i      25,080         85,080
               #12                                                                                                60,000

               #13                                                                                                34,378             34,378                              34,378

                                                                                                                     275,165            275,165                           275,165
               #14


                                        TOTAL             954,995              146i337                               869,543            4,970,875  1366      431          317,306
                     Includes       Central       Librarl Service















                                                                       --7



                                                                                                                                          3 6
            @Develbpmental                                                  100.000                   20.000      120,qpR.      300.000  ----
                                                                                                      Not
                                                                           420,000
                                                                                                                       qp,
            @unspec. Proi.
                                 450,000
                                                                                                                                          141,
                                                                                         908.0   0   265,600     1.173.600    2.430,384
            .CORE             i   908.000*
                                                                                                                                                6@


                                                                                                                               9   50(.
            !#2                                                                                                                           _..138,695
                                                                                                                                118,486      172,053
            :#3
                                                                                                                   ---         26,75         32.698
            #4
                                                                                                                                    000

                                                                                                                                          @31,   004
            ,#6R
                                                                                                                               5
            #8
                                                                                                         850       5   650        6.615
                                                                                              8LO.
            '#9
                                                                                                      ---         ---         _3T,4
              10


                                                                                                                  ---           110,000      155,980
                                                                                                                               76,493         76,493
            1#13
                                                                            350,486      15   4@86                 350.486      817,701    ."817,701

                                                                            870,486      2,233,286   286,450    2,519,736     5,961,711   7,088,747
                                1 362,800

                    Includes Central Library    Service





            WESTERN PENNSYLVANIA W                 -5-            RM 41-03  (AR-1-CD)


            Geography and Demogr  h

            The Western Pennsylvania RMP covers 28 counties, six of which  also  have
            ties with surrounding RMPS. The population is  approximately  four  million
            excluding the three shared counties which have predominant ties with
            other regions. The three major metropolitan areas in  the  Region,  Pitts-
            burgh, Altoona and Johnstown, all are reported with declining  popu  ations
            in the 1970 census. The mountainous nature of the area  has  resulted  in
            traditionally isolated communities.

            The western border of the State is the Region's border although the Region
            rep6r% significant interest in Western Pennsylvania activities by residents
            of the Youngstown, Ohio area and the Steubenville, Ohio -  Weirton,  West
            Virginia areas. The West Virginia border on the  south  rather  accurately
            reflects the southern border with some fringe overlap.  To the north, three
            'counties, Erie, McKeon and Potter, Appear to relate more closely with
            Western New York.


            The eastern border of the region is probably best considered as  being  in
            the area of Bedford, Blair, Center and Cameron  Counties.  Bedford,  Blair
            and Center also relate to the Susquehanna Valley Region.

            The Region has one medical school - in the University of Pittsburgh  -  and
            is served by approximately 4,100 active practicing physicians  and  15,500
            active nurses, 13,000 of which are located in hospitals.  There are 12,300
            LPNs in the.area and 137 nursing homes with approximately 10,000 beds.  The
            school of Allied Health Profession in the University of  Pittsburgh,  was
            established within the last three years. There are 43  Schools  of  Nursing
            in the Region, almost half of which are in Pittsburgh.

            Ninty-four acute general hospitals are located in the  Region with a
            combined total of 19,150 beds.

            Regional Development

            In the summer of 1965, the Dean of the School of Medicine met with approxi-
            mately 50 medical and hospital leaders in Western Pennsylvania  to  discuss
            the recently enacted legislation creating Regional  Medical  Programs.  It
            was agreed that the Dean should proceed with an application for  funds  to
            support RMP planning.  The Hospital Council for Western.Pennsylvania endorsed
            the plan and the Hospital Planning Association of Allegheny  County  made
            available a staff member who assisted a working group of faculty  from  the
            Schools of Medicine and Public Health in the preparation of an application.

            The University Health Center of Pittsburgh (a corporation composed of the four
            large independent hospitals affiliated with the University of Pittsburgh for
            teaching, training and research) was designated as the applicant organization,
            and a five-man steering committee was formed (Drs. D. A.  Clark,  Campbell
            Moses., K4 D Roger8i and Messrs. R. M. Sigmond and  Steven  Sieverts).  A
            32-member A@visory Committee was appointed by Dr. Cheever who was the Dean
            at that timei



         WESTERN PENNSYLVANIA RMP             -6-                RM  41-03  (AR-1-CD)
         The initial planning year was funded beginning January 1967 and  in  general
         the Region was a very slow starter. The first planning  year  was  extended,
         without additional funds, for a three-month period. This  action  was  taken
         following staff's review of the first year's progress reported by  the  Region
         which generated deep concerns. Most of the difficulty seemed  to  stem  from
         lack of full-time leadership and failure to attract promising staff.
         In January 1968 Dr. Robert Carpenter joined the staff and the following
         June became the full-time Director. The organization  was  streamlined,  staff
         was recruited and progress became evident.  There was a deliberate effort
         to regionalize early and nine area advisory committees were formed.
         The Region's Grant Review Committee met in October 1968 to  consider  twelve
         operational proposals which constituted the genesis of the  Regionis  opera-
         tional efforts.  The Regional Advisory Committee approved the following
         seven proposals of the original twelve for submission to RMPS:
                 #I-Establishment of a Regional Postgraduate Faculty of Medicine
                 #2-Hypertension Management, University and Selected Regional Hospitals
                 #3-Regional Program for Nurses in Heart Disease, Cancer  and  Stroke
                 #4-Emergency Resuscitation Team Project
                 #5-Regional Program for Treatment of Kidney Disease
                 #6-Program for Long-Terin Training of Nursing Home Personnel
                 #7-Establish@ent of a Regional Medical Program Library System
         These activities, combined with Core, constituted the  Region's  first  opera-
         tional application requestin  $2,034,413.
                                     9
         Following receipt of the application, WS site visited the Region in
         February 1969. The visitors found that  previous  problems  identified  during
         the planning period had been quite satisfactorily resolved and there was
         consensus that there was great potential in the Region.  The team recommended
         funding for six of the seven proposals; the kidney project  was  returned  for
         revision. The visitors noted, however, that the  impetus  of  project'activity
         was still based centrally in-the university setting and that there was
         impatience within the Community Involvement Committee  regarding  the.extent
         of attention to the urban poor.
         The April,1969 Review Committee accepted the site team's recommendation  of  a
         first operational year funding level of $1,060,883.  May 1969 Council reduced
         the recommended level to $934,041 for the first year because  of  a  temporary
         "hold" on all cardiopulmonary resuscitation projects  (the  Region's  proposal
         #4). After the special review of the proposal, the project  was  later  funded
         at a reduced amount.
         During the Regionts first operational year, it submitted two additional
         proposals: #8, Laurel Mountain Home Health Aide and  #9,  Training  of  Cancer
         Chemotherapists for the Community Hospital.  These  activities  were  approved
         but no additional funds were awarded to activate  them.  However,  the  Region
         activated project #8, at a sharply reduced level, at the  beginning  of  its
         second operational year through carryover funds, and two months later
         activated project #9 at a somewhat reduced level  through  rebudgeted  funds
                                                                                          I

         from Core and three projects.




            WESTERN PENNSYLVANIA  RMP                -7-             RM  41-03   (AR-1-CD)
            The Regi on's ap lication for its  second  year  operational  funding  included
                           p
            the amount of the commitment, plus a request  to  use  $235,000  balances  from
            first year funds. They proposed to use these funds  in  two  ways:  (1)  to
            conduct six feasibility studies and (2)  to  activate  the  aforementioned
            approved but unfunded activity and to replenish    the retrenched  budgets  in
            most of the remaining projects.

            Staff's review of the progress reported on the  first  year  of  operations
            and the plans described for the second year led to  a  consensus  that  the
            Region had exhibited growth and maturity  under  vigorous  leadership  of  both
            the Director and Core staff. An award was  made  beginning  July  1,  1970  in
            an amount of $1,160,391 which represented  the  full  commitment  plus  $226,350
            reauthorized  carryover.

            Under the Anniversary Review and Award system,  this  Region  had  no  options
            to submit requests for additional  operational  activities  during  its  secon
            operational year. The  present  application  reflects  the  Region's  decision
            to submit a triennial application on its  anniversary  rather  than  an  appli-
            cation geared only to its plans for next  year.  In  this  regard,  staff
            concluded in its review of the application that the Region had developed
            a viable and attainable plan for the next three years.
            The following chart displays the Region's funding  status  at  the  time  this
            application was developed; the levels of funding  for  the  continuing  life  of
            ongoing projects and specific new activities, as well  as  the  effect  of  its
            growth funding  request:

                                                               Projected.For   the  Triennium

                                            Present  Funding  Ist  Year  2nd  Year 3rd  Year

            Central Services
              Core  staff  activities        $594,191         @694,385    $798,000  $878,000
              Central Library Service           -0-              -0-        30,000   30,000
            Developmental   Component           -0-            ioo,ooo    100,000   100,000

            Project Activity
              Ongoing  projects  and          654,200          591,576    273,332     4,800
              their  continuation  or
              Renewal

              Specified new projects            -0-            371,589    369,543   350,486
              and their continuation

              Unspecified   "growth"            -0-              -0-      400,000   870,000
              activities  and  their                                                (includes
              continuation                                                           $420,000
                                                                                     for new
                                                                                     activities)


                                            $1,248,391       $1,757,550   $1,970,875 $2,233,286




           WESTERN PENNSYLVANIA P14P                 -8-           RM  41-03  (AR-1-CD)

           Organizational Structure and Processes
           The Regional Advisory  Committee,  originally developed as a  32-member  body
           now is composed of 48  members.  It  reflects good  geographic  and  discipline
           representation. The  Executive  Committee  is composed  of.the  Chairman  and
           the Secretary of the full Committee  and  the Chairmen of the following
           specialized Committees:

                   Operational Grant Review Committee
                   By-Law  Committee
                   Nominating Committee
                   Community Involvement Committee
                   Heart Committee
                   Stroke  Committee
                   Cancer  Committee
                   Health Care Education Committee
           While the full membership of the  Advisory  Committee  and  its  sub-comittees
           displays very good geographic distribution,  the  Executive  Committee  reflects
           predominantly Pittsburgh  representation.  However,  this  Region  developed
           Area Advisory Groups early on and is presently functioning with, nine
           such groups involving some 465 persons committed to improving medical
           care in their areas. Under Appendix C,  in  the  application,  the  planning
           accomplishments of each area and its participation  in  the  Region's  ongoing
           activities describe good regionalization.  The Area Advisory Group structure
           is similar to the Regional Advisory Committee in that categorical sub-
           committees have been formed.
           These Committees, both at the Regional and Area  level,  serve  to  identify
           needs' design the outlines of projects required to  meet  those  needs,  and
           identify leadership for the projects.  In addition to these Committees,
           the Region utilizes the Task Force approach with a  Task  Force  on  Primary
           Care being recently appointed. Consultants are  used  to  make  site  visits
           to review proposed activities and evaluate ongoing projects.


           All operational proposals,  whether stemming from  Area  Groups,  Committees  of
           the Regional Advisory Committee or Core  staff  identification,  are  reviewed
           by the Operational Grants Review Committee.  That Committee recommends
           priorities among the proposals.  Following this review, the proposals are
           submitted to the Regional Advisory  Committee.  The  upcoming  site  visit  will
           afford an opportunity to inquire into the  specific  processes  of  this  system
           and will report on its effectiveness.

           Regional Objectives
           The twelve program objectives established by the  Region  have  been  assigned
           three priority weights    highest, high and  important.  Briefly  stated  they
           are:

                   Priority                           Objective

                    Highest               #1 - To assure that  modern coronary
                                          care is available to all residents
                                          in the Region





            WESTERN PENNSYLVANIA RMP                -9-            RM 41-03 (AR-1-CD)


                    Priority                          Objective

                     High                  #2 - To develop the  Region's  system
                                           for primary care by  providing  ready
                                           access for rural and urban  areas  to
                                           the health care system

                     High                  #3 - To develop an adequate continuing
                                           education program for the  health  pro-
                                           fessionals in the Region

                     High                  #4 - To develop in  hospitals  caring
                                           for cancer patients, groups  of  health
                                           professionals with specific competence
                                           in oncology

                     .High                 #5 - To develop a Regional  network  of
                                           facilities to support  patients  with
                                           chronic renal disease and to improve
                                           the care of patients with  acute  renal
                                           disease

                     High                  #6 - To define the most  adequate  care
                                           programs for patients with stroke

                     High                  #7 - To develop projects to attack
                                           diabetes and emphysema

                     High                  #8 - To provide adequate extended care
                                           and long-term care in an effort to
                                           limit the health care costs,

                     Important             #9 - To continue to document  the  health
                                           care problems of the Region

                     Important             #10 - To stimulate a  public  information
                                           program, using existing agencies, parti-
                                           cularly the community hospital

                     Important             #11 - To improve the treatment  and  care
                                           of heart disease other than coronary
                                           heart disease

                     Important             #12 - To expand the area of  impact  of
                                           existing projects

            Within these objectives, the Region has developed a  strategy  for  each
            activity with a time schedule and identified leadership roles.  This consti-
            tutes the operational plan for the Region.  In reviewing this portion of
            the application, staff felt the objectives and priorities were clearly
            stated and well related to the Region's capabilities and opportunities.
            Heart disease, by virtue of the more abundant opportunities to act in this
            Area became the highest priority categorical concern.



           WESTERN PENNSYLVANIA RMP                  -10-             RM 41-03 (AR-1-CD)

           Present App ication

           The Developmental Component.
           The Region requests developmental funds  of  $100,000  for  each  of  three  years.,
           The ability to move expeditiously to solve problems is cited by the Region
           as an important factor to program growth.  Western Pennsylvania MAP made
           extensive use -last year of reauthorized unex'pended funds to carry out a
           variety of feasibility studies to move into this area.
           Specific approaches are  described  as  to  how  the  proposed  developmental  funds
           will be utilized in the areas of Coronary Care, Primary Care, Continuing
           Education, Cancer Care and Stroke Care.  Generally, the approaches may be
           described  as  planning  studies,  specific  investigations,   demonstrations,   and
           seed money.
           The review process to govern the investment of developmental funds is the same
           as that which exists for review of investment of other program funds.  Howevek,
           requests for support limited to 12 months and less than $10,000 may be
           a proved by the Director subject to review by the Advisory Committee.  Invest-
            p
           ments of longer duration and requiring greater funding will be reviewed by
           a site visit team, the Operational Grant Review Committee and the Advisory
           Committee.  All  developmental  component  activities  must  have  the  approval  of
           the appropriate Area Advisory Groups.
           Request for Growth Funding In the Second and Third Years of the Triennium
           The Region projected both its  operating  plan  and  its  budget  based  on  several
           hypotheses. One of these  is  that  the  program  base  would  be  permitted  fiscal
           expa nsion in 1972,  provided  adequate  numbers  of  good  proposals  were  submitted
           to RMPS. Another  was  that  it  would  be  necessary  to  develop  program  support
           from non-Federal sources if  true  partnership  is  to  evolve  between  the  Federal
           and private sector.
           The budget request for the  second  year  of  the  triennium  (the  fourth  operating
           year  of  the  program)  includes  $400,000  for  projected  growth  activities.  In
           the main, these activities are now  in  the  study  and  planning  stage  with  time
           schedules plotted  and  leadership  roles  identified.  Some  are  reflected  in  the
           grid included in the annual report of the Regional Advisory Committee and
           others  are  expected  to  generate  from  Developmental  Component  activities.  For
           example, the  Pittsburgh  Model  Cities  Program  is  identified  for  a  leadership
           role in a program scheduled'for  activation  in  July  1972  to  assist  local  pro-
           viders to link institutions in the Pittsburgh Model City Area to develop a
           comprehensive primary care and referral system for the area residents.
           The.budget request for  the  third  year  of  the  triennium  includes  $450,000  to
           continue the activities  inaugurated  the  year  before,  and  $420,000  to  initiate
           new ones.  Presently  funded  projects  are  scheduled  for  termination  in  these-
           years, so that.while the net  effect  is  A  gradual  increase,  the  budget  becomes
           a revolving account.
           The site visit team   plans to learn  more  about  these  leavening  activities  and
           will report to the Committee on them.





            WESTERN PENNSYLVANIA RMP                                  RM 41-03  (AR-1-CD)


                                                                            Requested
                                                                           Third Year
            (,ORE                                                (First Year of  Triennium)
                                                                           $694)385

            Core is presently supported at $594,191 of which approximately $75,000
            is reauthorized unspent program funds from the preceding  year.  The  Region
            estimates a balance of $27,000 in this component this year.

            The current staff consists of 35 full and part-time  personnel.  Two  existing
            professional positions are vacant and are currently being recruited (a Cardio-
            logist and a Graphic Artist).  This application requests three new
            professional positions in the first year of the  triennium--an  Assistant
            Director of Evaluation, an Assistant for the primary care program and  a  Nurse
            Specialist in continuing education. In addition, two  new  technical  positions
            are requested and additional secretarial help. The core  budget  escalates  in
            years two and three due to limited staff additions, salary increases, and
            the inclusion of an ongoing operational project (#7 Library System) as a
            regional resource. The "othe:e'category shows a marked increase in  the  second
            year of the triennium due to a doubling of the rent in a  lease  negotiation.
            Similar increases are shown in the supplies category due to the inclusicin  of
            the photocopying charges which move to the core budget in the regional library
            resource.


            The application describes an energetic and productive core  staff  operat ion
            moving in the areas of planning, support in identifyin  needs, assistance with
                                                                   9
            project development and in evaluation of  operational  effectiveness.  In
            addition, the application reports on some 20 feasibility  studies  conducted
            during the previous year, generated with assistance from the  central  staff,
            but conducted by members of the program outside the core staff.  Four  of  the
            five now projects included in this application stemmed either  from  planning
            or feasibility studies conducted with core funds.

            The structure of the Core staff is divided into the following categories:

                   Office of the Program Director

                   Medical Practice & Evaluation - includes an  associate  director  and
                          assistant directors for Oncology, Cardiology, Continuing
                          Education and Evaluation


                   Regionalization Services - includes an associate  director  and  four
                          Area Liaison Representatives

                   Nursing and Allied Health Professions - includes a nurse  who  is  an
                          Assistant Director, a Nurse Specialist in  Continuing  Education,
                          a Cancer Nurse and a Physical Therapist

                   Communications - inciudes an Assistant Director, an Editorial
                          Assistant and a Graphic Artist




          WESTERN PENNSYLVANIA RMP                 -12-          RM 41-03 (AR-1-CD)

                  Hospital Liaison - includes an Assistant Director  and  an  Assistant
                        Planner

                  Fiscal Administration    includes an Assistant Director and-an
                        Auditor

            Request                                                         Request
          Fourth Year                                                    Fifth Year
           $828,000                                                        $908,000

          Continuation Projects

          The Region requests continuation of the following seven projects.  Five
          of them are moving into their third year of operation and  two  (#8  and  #9)
          go into their second year.

                                                                               Requested
          Project #1 - Establishment of a Regional Postgraduate Faculty         @?35,450
                       of Medicine.

          This project was supported last year at a  level  of  $39,000.  Continued
          support is requested to pursue the original objectives of:  (1)  to  establish
          a faculty of community physicians in the Cambria-Somerset  Area;  (2)  to
          improve postgraduate medical education in hospitals in that Area; (3) to
          assist each hospital medical staff to develop its  own  continuing  education
          program; (4) to establish a communications  link  between,the  University  of
          Pittsburgh research and educational resources and hospitals located through-
          out the Area; and (5) to facilitate exchange, for  educational  purposes,  of
          physicians in the Cambria-Somerset Area and those at the University.
          Originally these efforts were directed toward the  staffs  of  two  hospitals
          and one County Medical Society. It expanded  to  serve  three  additional
          hospitals in Johnstown and in the upcoming year will extend  to  the  Altoona
          area. The concept has been taken up by other Areas  and  the  Region  antici-
          pates that the Faculty ultimately can be supported by  funds  from  hospitals,
          hospital staffs, and professional societies  which  it  serves.  The  project
          is entering its last year of RMP committed support.

                                                                               Requested
          Project #2 - Hypertension Management, University and Selected         $97,500
                       Regional Hospitals
          This project was supported last year at a level of $88,000.  Continued.
          support is requested to pursue the original  objectives  of:  (1)  to  inform
          practicing physicians about modern diagnostic  and  therapeutic  methods  for
          patients with hypertension; special emphasis is given  to  the  diagnosis  of
          surgically remediable hypertension and the medical  management  of  essential
          hypertension; (2) to provide access to modern diagnostic techniques for
          patients with hypertension; (3) to identify leadership for  the  care  of
          hypertensive patients in communities throughout the Region; (4) to learn the
          problems faced by community physicians treating  hypertensive  patients;  and
          (5) to bring together a,group of health professionals and health institutions
          to support the Regional Program.






          WESTERN PENNSYLVANIA @MP                -13-           RM 41-03 (AR-1-CD)

          Originally, eight hospitals participated in this project.  It has proven
          popular and has been expanded to include nine additional hospitals.  The
          application states some fees are generated from certain lab  tests  performed
          and the amounts collected are returned to the grant.  The site visitors plan
          to inquire about these arrangements because the funds cannot be traced in
          the fiscal information presented. The participation in  this  project  repre-
          sents good regionalization.

          The me ical practice data already collected will be used to  measure  the
          project's impact of the educational program in terms of changing habits of
          medical practice for hypertensive patients. Also, a  questionnaire  is  being
          developed to evaluate (1) the way most practicing physicians diagnose and
          manage hypertensive patients in the hospital and their offices and (2) the
          possibility of developing a pilot detection and  treatment  progr'am in selected
          communities.  The survey is to be initiated in January 1971 and future plans
          hinge on the survey results4  This project is entering its final year of
          RMP committed support.

                                                                              Requested
          Project #3   Regional Program for Nurses in Coronary Care            $118,486


          This project was supported last year at a $106,700 level.  Continued
          support is requested to pursue the original objective of  enriching  the
          knowledge and enhancing the skills of nurses caring for patients with
          acute myocardial infarction.

          A total of 257 nurses graduated in the first six courses and it is antici-
          pated that 200 more will be trained in the remaining four University courses
          scheduled for the last six months of this operational year.  In addition,
          19 nurses have been trained in the Clearfield satellite program  and  18
          in Johnstown. In all, the three programs have  provided  coronary  nurses
          for 65 hospitals in 19 Western Pennsylvania Counties and two hospitals in
          Ohio.  All of the courses have been filled to capacity.  Evaluation of the
          training has shown that 80% of the 257 graduates plan to work in coronary
          and intensive care units as compared to 40% prior to the course and that
          training has resulted in both increased knowledge and  improved  performance.
          Although this project is entering its final year of RMP committed support,
          the information included in the application indicates the  Region  feels
          there is a continuing need for this type of activity in the  Region's  future
          plans.


                                                                            Requested
          Project #4 - Emergency Resuscitation Team Project.                 $26,875

          This activity was supported last year at a  $35,500  level.  Continuation
          funds are requested to pursue the following objectives: (1) to  train  a
          team nucleus for individual hospitals; (2) to assist these  hospitals  to
          train other personnel in emergency resuscitation; (3) to train members of
          teaching teams for each Heart Association Chapter to provide  for  continuing
          education in emergency resuscitation; and (4) to help hospitals  to  evaluate
          the success of their team's efforts.



          WESTERN PENNSYLVANIA RMP               -14-              M4 41- 03 (AR-1-CD)
          This activity is jointly sponsored by the Pennsylvania Heart Association
          and the University of Pittsburgh.  The courses are held in Pittsburgh.
          Five courses have been held and five additional courses are planned during
          the remaining six months of this operational year. Twenty-four  hospitals
          participated in the first five courses.  Three of the remaining courses were
          fully subscribed when this application was prepared. At the end of  this
          project, a survey of the Region's hospitals will be repeated to determine
          the number who have instituted full emergency resuscitation team programs
          as a result of this project.
                                                                            Requested
          Project #7  Establishment of 6 ReRional Medical Program Library    $50,000
                      System.
          This activity was supported eta similar level last year. The Region feels
          this project has met with considerable success in meeting the  following
          objectives: (1) to stren then local hospita I libraries; (2) to promote
                                 9
          cooperation among these.libraries; (3) to disseminate information directly
          in response to requests for copies of individual,articies; and (4) to provide
          information in response to requests for a search of the literature for
          information regarding a specific problem.  Considerable statistical-use data
          is provided.  Although,strongly endorsing the continuation of this service,
          the Regional Advisory Committee recommended that support be sought  from
          other community resources after its final RMP funding year.  Hospitals will
          be expected to contribute as well as the Regional Medical Library in
          Philadelphia. Such support is likely to be inadequate and, the Region's plans
          for the second and third year of the triennium are that this activity  be
          continued at a $30,000 level as a core activity.  A total need for the
          expanded activity is estimated at $75,000.
                                                                                  sted
                                                                              $75,000
          Project #8 - Laurel Mountain Home Health Aide Proiect.
          This project was activated last year entirely through carryover funds  at
          a $76,600 level. The activity was approved by Council for  a  three-year
          period and this application requests funds for the remaining two  years.
          It is sponsored by the Community Nursing Service of Johnstown, Pennsylvania,
          Inc.  The original objective was to make available to patients in a rural
          area of four counties (Bedford, Cambria, Clearfield and Somerset) adequate
          home health services where such services had not previously existed.  Since
          the project was activated, the sponsors have expanded the geographic scope
          by opening a satellite agency in Glasgow, in the northeastern section  of
          Cambria County.  Later, the satellite was moved to a location more central
          to the service area.  In November, another satellite was opened in Jennerstown,
          Somerset County. A hospital-based agency is scheduled for April  1971  in
          Bedford County. Rt4P funds are only used to pay expenses for the training  of
          home health aides.
          This activity was operational for only three months at the time the application
          was prepared.  The Region plans to evaluate it on the basis of quality of care
          @and cost effectiveness. Approximately $38,000 was expected to be  unexpended
          in this project's current budget.

          Second Yea     uest
                $80,000





            WESTERN PENNSYLVANIA RMP                   -15-            RM  41-03  (AR-1-CD)

                                                                                      Requested
            Project #9 - Training of Cancer'Chemotherapists for the Community           $44,820
                          Hospital.

            This project was activated  September  1,  1970  through  rebudgeted  funds  at
            a $32,400 level. It  seeks  to  provide  training  in  Chemotherapy  to  six  practi-
            tioners from the Region every six months through preceptor-directed clinical
            experiences over a six-month period on  a  one  day  per  week  basis.  It  is
            sponsored by the  Western  Pennsylvania  Hospital  Association  and  was  begun  with
            the establishment of an  office  in  the  Mellon  Pavilion  at  Western  Pennsylvania
            Hospital.  Five students began their preceptorship program on November 1, 1970.
            In addition, a symposium  on  Cancer  Chemotherapy  was  held  in  November  attended
            by 42 physicians, 13 registered nurses, eight residents, seven medical
            students and two interns.

            It is planned that  the  preceptor  group  and  the  community  chemotherapists
            will develop guidelines for the use of chemotherapy in the community hospitals
            of the Region.  Evaluation  in  the  future  will  include  particular  attention  to
            the register of  patients  brought  under  treatment  by  the  participating  trainee
            physicians.  In addition, the physician will provide, each quarter, a 8escrip-
            tion of the progress of patients under his care.  Changes in referral patterns
            and the establishment of cancer teams will be identified.

            Six students were being recruited for the next preceptor program at the time
            the application  was  prepared.  The  Region  expected  no  difficulty  in  filling
            the course.

            Full second and third years are  requested  with  a  partial  fourth  year  to
            afford the activity three years of operation.

            Third Year                                                           Fourth   Year
             $46,995                                                                $4,800

            Renewal Project
                                                                                     Requested
            Project #6R- Training of Nursing Home Personnel.                          $143,445
            When this activity was originally submitted as part of the Region's
            initial operational  application,  three  years  of  support  were  requested.
            However, Council approved it as  a  demonstration  project  for  a  period  of
            two years.  While there was no question that the training was aimed at
            filling a documented need,  Council  felt  that  relationships  needed  to  be
            established between the  referral  agency,  the  hospital  and  the  nursing  home,
            and the curriculum ne6ded to be described.

            This activity was funded atlevels  of  $125,000  and  $137,500  for  its  first
            and second years.  The  application  states  that  its  objectives  to  be  pursued
            in the two-year renewal period are: (1) to improve the quality of nursing
            service; (2) to improve  the  quality  of  administration;  (3)  to  improve  dis-
            charge planning procedures; and (4) to evaluate their own services.  It will
            provide instruction  by  a  multidisciplinary  team  over  an  eight-month  period




          WESTERN PENNSYLVANIA RMP                  -16-              RM  41-03   (AR-1-CD)

          and follow-up for the following 12 months.  Classroom instruction is
          directed toward the administrator and at-least one charge nurse from each
          participating  nursing  home.  Classroom  instruction  is  augmented  by   regularly
          scheduled visits to the homes.

          Up to now, the  didactic  portions  have  been  presented  only  in  Pittsburgh.  In
          the renewal period,  similar  programs  will  be  presented  outside  Pittsburgh  to
          allow for involvement of more of the Region's nursing homes.

          Nineteen homes enrolled in the  first  course  and  23  in  the  second.  Approxi-
          mately one-third of the  extended  care  facilities  in  the  Region  have  partici-
          pated in this project.
          As the project continues, the Region plans to focus increasingly on the
          problem of adequate discharge planning.     Still to  be  developed  is  a  mechanism
          to assist the exchange of patients between hospitals and nursing homes to
          reduce  unnecessary  hospitalization  and  to  provide  appropriate  secondary  care
          for nursing home patients whose condition deteriorates.

          Second Year Request
          $146,337

          New Operational Projects
                                                                                     Requested
          Project #10 - Early Care for Suspected Coronary Patients.                  $37,424
          This one year proposal revolves around the Region's highest priority
          objective.  There are no other early care experiments in the Region
          although one presented formerly to the Regional Advisory Committee was
          rejected because of its reliance on telemetry and large numbers of in-
          completely trained-personnel.
          This mobile unit will operate out of Westmoreland Hospital located in
          Greensburg, a community of  17,800  persons,  35  miles  east  of  Pittsburgh.  It
          maintains 270 beds and serves a semi-rural population of 80,000.  This hospital
          established one of the  first  coronary  care  units  in  the  Region.  Itis  served
          by a  community  ambulance  service  offering  24-hour  service.  Area  residents
          recently presented the  service  with  a  fully  equipped  coronary  care  ambulance.

          The State Nurse Practice Act  has  recently  been  amended  to  permit  this  experi-
          ment. The project will study  the  cost  and  effectiveness  and  an  early  care
          system that  generally  follows  traditional  mobile  procedures  but  provides  for
          a decision by the coronary nurse whether the patient is to be evaluated in the
          emergency room or is to be taken directly to the coronary care unit.

          The November 1970  Council  minutes  include  the  following  policy  expression:
          "Mobile Coronary Care Units:  Experience  with  such  units  to  date  has  demon-
          strated that initial costs are  high  and  experience  to  date  has  not  developed
          capability to predict the degree of  success  that  can  be  expected  for  given
          combinations of organization, staff, equipment, population and to assure
          geographic coverage  and  regional  cooperation.  In  sub  ective  comparison,  it
          seems likely that the sum required to demonstrate a mobile unit program         would




            WESTERN PENNSYLVANIA RMP               -17-             RM 41-03 (AR-1-CD)
            produce greater benefits if invested in a well-planned preventive program
            instead.  Council asked RMPS to advise Regional Medical Programs to fund
            no new mobile coronary care projects."
            This proposal had been considered by the Regional Advisory Committee prior
            to the communication of Council's action.

                                                                              Requested
            Project #11 - A Regional Program for Patients with Sickle Cell     $50,000
                         Anemia.

            This one-year proposal, sponsored by the University of Pittsburgh, is
            designed to assist the 189,000 members of the black community.  It aims to:
            (1) improve the understanding in the black community of these diseases;
            (2) identify patients with sickle cell anemia and related hemoglobinopathies;
            (3) develop a better understanding of the value of available methods for the
            medical and social support of patients with hemoglobinopathy through innova-
            tive medical and social.care system; (4) provide continuing education for
            physicians caring for patients with sickle cell disease; (5) develop a
            facility to screen interested groups for sickle cell trait and to develop an
            understanding of the value of counseling for those found to have this genetic
            trait and (6) stimulate research aimed at correcting the consequences of
            inherited hemoglobin abnormalties.
            Health practitioners working with the black community have tried to organize
            .an effortifor patients with sickle cell disease in Pittsburgh for over ten
            years.
            Screening for sickle cell trait will be offered initially to employees of
            the Health Center4  Later, the screening will be extended to black children
            in selected schools.  The second stage screening will not be undertaken until
            there has been an opportunity for parents to understand the intent.  Counseling
            will be provided by members of the Sickle Cell Society.
            The evaluation will be accomplished through seven mechanisms which, generally,
            include recording the number of educational devices developed, an opinion poll,
            changes in the use of medical facilities by patients, the number persons
            screened And the incidence rate, and the number of persons referred to the
            clinical research facility and the use of new treatments

                                                                               Requested
            Project #12 - Regional Program_for Patients with Diabetes           $50,000
                         Mellitus.
            This two-year proposal aims to: (1) study the diagnostic and therapeutic
            practices used for hospitalized patients with diabetes; (2) provide a
            Regional consensus as to needed diagnosis and treatment programs; (3) identify
            for practicing physicians, their colleagues with a special interest in
            diabetes and endocrinology; and (4) strengthen the relationship between these
            physicians and those in the Region with similar interests in the Health Center
            teaching hospitals in Pittsburgh.




                                                                 Rm 41-03 (AR-1-CD)
          WESTERN PENNSYLVANIA PLMP
          Pennsylvania is second among the 50 States in the reported mortalit
                                                                            y from
          diabetes mellitus.  Six hospitals have indicates their willingness to
          participate in this project.  Three of these hospitals are in Johnstown,
          one in Indiana, and two in Pittsburgh.  The two Pittsburgh hospitals will
          provide instructors.  The project format provides for the review of existing
          records with a formal data collection instrument, monthly meetings for
          physicians to be held in each participating hospital with a panel of consultants,
          and visits by community physicians to the metabolic-endocrine unit of the
          Magee-Womens Hospital under direction of the Project Dire6tor.
          Evaluation will pursue the number of physicians attending, hospitals 'arti(,-i-
                                                                               P.
          pating, records reviewed, educational.opportunities identified, and programs
          presented in response to these opportunities.  To evaluate the effect of the
          project on the use of diagnostic techniques in the Region, the use of the
          serum - insulin measurement in participating hospitals will be followed and
          evaluated in terms of Regional consensus as to the clinical value of this
          determination. the cost of the'determination also will be  identified.

          Second Year Request
             $60 000
                                                                            Requested
          Project #13  Bu"cktail Area Emphysema and Pulmonary DiseaLe        $42,115
                       Project.
          This is atwo-year proposal to improve the.care of patients with emphys
                                                                                 ema
          and other respiratory diseases.  To accomplish this the project will:
          (1) develop new inhalation therapy departments in five Area hospitals;
          (2) demonstrate the value of a screening program for chronic obstructive
          pulmonary disease; (3) establish a respiratory intensive care unit in one
          hospital to serve the,Area; (4) provide continuing education on the  diagnosis
          and treatment of pulmonary disease for Area health professionals; (5) stimulate
          a developing spirit of cooperation in the four-county Area; and (6)  establish
          communication between health professionals and institutions in that Area  with
          those in the rest of the Region@
          The request for the project generated from the Bucktail Area Advisory Group
          some 15 months ago following a survey of each of the hospitals in the area.
          The project will serve a 3,000 square mile area of the northeastern part of
          the Region with a population of.173,000 served by 118 physicians in general
          practice.  There are seven hospitals in the area only two of which have
          established inhalation therapy programs.
          The proposal includes four components: Basic training for inhalation therapy
          technicians, screening, respiratory care units and continuing  education.  The
          first component appears to be in conflict with RMPS policy on training of
          inhalation therapists and this point will be explored during the site visit.
          Reasonable evaluation methods have been described for each of the  components.

          Second Yea  Request
              $34,378





          WESTERN PENNSYLVANIA RMP                   -19-               RM  41-03  (AR-1-CD)
    0                                                                              Requested
          Project #14 - Renal Disease.                                              $192.9050

          The original application for   operational status from this Region included
          a three-year program for the   treatment of kidney disease.  The funds
          requested were in the neighborhood of  $700,000  for  each  of  the  three  years.
   f      It was an all-encompassing proposal and the April 1969 Review Committee
          concluded that it was rather ambitious and recommended that it be returned
          for revision to reflect primarily the training aspects.  May 1969 Council
          concurred in this recommendation.


          This proposal, for a three-year program, represents the revised project.
          However, in the interim, RMPS Guidelines for Planning a Comprehensive Regional
          Kidney Disease Program, have been issued and preliminary review of this
          proposal raises questions as to whether the revised version complies.

          The site visit team will explore this situation and report on it to
          Committee.


          Second Year Request                                           Third  Year  Request
              $275,165                                                       $350,486






























                                                                              RMPS/GRB
                                                                                3/8/71







                                                                                WP/RMP Area
                                                                                Advisory Groups

                                                                                Shared Relation-
                                                                                ship with Susque-
                                          [[III ILT                             hanna Valley P-'4P
                                                                                Affiliated with
       S TE RN                                                                  Western New York
                                                                                &MP
   PLi NIINSYLVANIA
   ,ri Li I 0 N               CRgtrr-ORD:
      -El D I C A L
   PR@OG'@qA,M


      Area Advisory Groups


      I (Crawfordi Forest,
       Venango, Warren)
     II Bucktail
    III Lai-mer
     IV'(Beaver, Butler)
      V Evergreen
     VI Southwest
    VI! Westmoreland
   VIII Laurel Mountains
     IX Appaladhian-Highlands








                               GR E                 s@





                                                            A PRIVILEGED COMMUNICATION



                              SUMMARY OF REVIEW AND  CONCLUSION OF
                                  APRIL 1971 REVIE14 COMMITTEE.


                         WESTERN PENNSYLVANIA REGIONAL MEDICAL  PROGRAM
                                    RM 00041-03     5/71


                         FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL


          .Recommendation:  Committee recommended that the Region be awarded $1,450,000
                           for each of three years including developmental component
                           funds. The ad hoc  panel  recommended  disapproval-of  the
                           revised kidney proposal, #14, on basis of technical merit.

                                               Requested                  Recommended
          ,Year                            Direct-Costs Only         Direct Costs 0 1
           03                                $1,757,550                   $1,450,000
           04                                $11970,875                   $1,450,000
           05                                $2,233,286                   $1,450,000


          TOTAL                              $5,961,711                   $4,350,000

          Committee Program Critique:  The recommendations of the March   10-11, 1971
                                       Site visit team were considered and unanimously
           'P-c omin nded -Or approval.  The Committee was impressed with the strengths of
          the Western Pennsylvania RIMP reported by the site'visitors--the program
          momentum generated in its,first 18 months of operational status, the
          rerionalization of its structure (with nine active sub areas each with a.strong
          local advisory committ6e) the demonstrated competency of the Core staff and
          its leadership, and 6 very knowledgeable and active Regional Advisory Committee.

          it was the consensus of the reviewers that the Region had proposed a viable
          three-year plan of growth.  The Committee agreed that the goals, objectives
          and priorities evidenced good strategic planning and that the progress
          reported bv the ongoing activities warrant continued support.

          The new operational activities proposed for the first year of the triennium
          were judged to be faithful extensions of the Rogion'g goals and objectives.
          'However, in view of the negative findings of the ad hoc panel with respect
          to the revised kidney proposal  project #14, Ren l@ i@sease was recommended
          for disapproval.  Also, project #10, Early Care for Suspected Coronary
          Patients, and those aspects of project #13, Budktail Area Emphysema and
          Pulmonary Disease, that concern the basic training of inhalation therapists,
          were not.recommended for approval in view of Council's policy.  With respect
          to project #10 the Committee noted that coronary care is the Region's highest
          priority; that the feasibility study preceding this proposal began in 1969;
          And that the proposal was approved by the Regional Advisory Committee prior
          to the enunciation of Council's policy with respect to such experiments.

           6 Review Committee agreed that the,-,West6rn Pennsylvania RMP had convincingly
           mongtrated the capability to receive developmental component funds.  The
           11-judged use of program funds last year for planning, feasi@bil-ity studies,




           WESTERN PENNSYLVANIA RMP                   -2-                    RM 41-03


           and seed money,,coupled   with the types of    investments describe  as
           developmental  opportunities  for  the  triennium  were  considered  in   arriving
           at this recommendation.

           The  reviewers  endorsed  the  very  favorable  impressions  of  the  site  visitors
           with respect to the Core staff role in this Region, its demonstrated
           competence, and its excellent leadership.  Committee agreed that an increase
           in the level of Core support was warranted.

           The site visitors had recommended, and the Committee agreed, that the
           Region's  review  process  meets  the  requirements  for   decentralization.   The
           process  involves  collaborative  efforts  of  staff  with  the  proposer,   technica
           consultants  from  categorical  committees,  task  forces  and  rea  a  visory   groups,
           on-site review by members of the Operational Grant Review Committee and
           technical consultation from within or outside the Region..  The area-wide CHP
           agency in the southwestern part of the Region is afforded opportunity to
           comment.

           The  Committee  approached  the  unspecified  growth   funds"   request   cautiously.
           The concept of  a  region  operating  within  a  broadly  described  triennial  p  an
           without  referral  to  Committee/Council  for  specific  project  approval  at   such
           times as  new  activities  ate  implemented  was  not  fully  discussed.  While  t  e
           committee approved  the  level  of  funding  recommended  by  the  site  visit  team
           (which provides "growth funding   11) Committee  did  so  with  the  understanding
           that  those  activities  now  only  generally,described  but  planned  for   implomenta-
           tion later  in  the  Rogionis  triennium,  will  be  submitted  through  the  review
           process for specific evaluation.

           The recommended level of support developed by the site visit team  and
           recommended for approval  by  the  Committee  was  arrived  at  in  the  following
           manner:


                   Core support                    $    650,000
                   Developmental Component              ioo,ooo
                   Operational Activities
                    (continuing, renewal
                     and new)                           700,000
                                                    $1,4-50,000

           No funds for  projects  #10  or  #14  were  included in these amounts.  Also,
           the reduction of  funds  for  project  #13  is  reflected  in  the  above  computations.

           ,Panel Technical Critique:  With respect to project #14, Renal Disease,.which is
                                         a revision of a previously submitted proposal, the
           Panel  recommended  disapproval.  While  there  would  sbe@  to  be  adequate   pro-
           fessional staffing to conduct the  roject in most respects, there were grave
                                                 p
           doubts  as  to  their  harmonious  relations  and  commitments.  Although  the   million
           dollars  earmarked  for  kidney  disease  activities  from  the  State  of  Pennsylvania
           has not yet been apportioned, this proposal lacks the element of coordination
           with other RMP: in  the  State.  The  reviewers  felt  that  training  periods  of  two
           ,and threeveeks were too short to be of real value.  The relationships of the
           hosp ital8 are not well worked out.


                                                                             RMPS/GRB
                                                                              4/22/71





                         E)EPAt-ifrAENT OF HEALTH, EDUCAi'ION, ATID ItiELFARE
                                        PUBLIC HEALTH SERVICE
                          HEALTH SERVICES AND MENTAL @IEALTH AbmlNISTRATION


             March 19, 1971
         to


      @9i)bject: Quick Report on Western Pennsylvania Site Visit March 10-11, 1971

         7'o: Acting Director.
             Regional Medical Programs Service

             THROUGH:  Acting Deputy Director
                       Regional Medical Programs Service


             The team was composed of the following members:

                 Leonard Scherlis, M.D., Chairman, Professor of Medicine and Chief,
                   Department of Cardiology, University of Maryland Hospital

                 Franklin G. Ebaugh, MbD., Doan, College of Medicine, University
                   Medical Center, University of Utah

                 Jobn,A. Mitchell, M.D., Deputy Director, California Committee
                   on Regional Medical Programs

                 Edith V. Olson, R.N., Nursing Coordinator, Rochester Regional
                   Medical Program

                 Frederic Westervelt, M.D., Assistant Professor Of internal Medicine,
                   University of Virginia Medical School

                 Gerald GArdell, Chief, Grants Management Branch
                 Rebecca Sadin,, Continuing Education Branch
                  oretta Brown,.Planning and Evaluation Branch
                 James Smith, Regional Development Branch
                  brraine Kyttle, Grants Review Branch
                 Clyd& C6u6hman, Regional Representative
                 Rodney C. Mercker, Grants Management Branch

             Briefly, the visitors came away-with concerns in some areas, but  with
             the   animbu6 impression that we had visited an energetic, effective
             Reg  ion.

             The areas of concern are:

             T@is is a rovider-oriented program that deeply  feels  the  politician
                       p                                                          9
            @o  health pare programs is the business of CHP    it sees this as  the







            Page     Acting Director, RMPS

            natural division between the two programs. It  candidly  attributes  its
            progress to its provider base. Agreement was reached  to  expand  its
            representative structure to include the social groups it serves.

            The visitors believe that many of the general responsibilities and
            specific assurances vested with Post grantees have been delegated in
            this Region to such an extent that the grantee may be a paper organization.

            The areas of strength:

            A tremendously energetic Core staff, bound together  by  unusual  espirt
            de corps and competence.

            An involved and knowledgeable Regional Advisory Committee  that  listens
            to and works well with its Local Advisory Committees.  The  Chairman  is
            a real plus.

            The talent of attracting the time and attention  of  University  faculty
            with strong action and comunity-oriented  bents.  These  are  volunteers
            and are not on the RMP  payroll.

            The knack of identifying local resources and good  local  leadership.
            Western Pennsylvania's terrain makes travel  difficult,  particularly
            during the winter, and even with a very stringent "attend or be dropped"
            rule, Local Advisory Committees and Regional Advisory Committee involve-
            ment is very good.

            A highly qualified group of nurses, deeply committed to  the  program
            both at the local level and particularly the Dean of the School of
            Nursing.

            The skillful use of feasibility studies and seed money  to  address  new
            priorities.

            Funding Recommendations:

                 Present Level              Requested Levels            Recommended
                  $1,248,391               03 yr. - $1,757,550          $1,450,000
                 ($  226,350 is            04 yr. - $1,970,875          $1,450,000
                 carryover from            05 yr. - @2,233,286          $1,450,000
                 the 01 year)

            In arriving at a recommended level, the consultants  computed  the  full
            amount for a Developmental Component, funds for some expansion  of  Core
            staff, and a revolving account for operational activities in the neigh-
            borliood of $700,000 which must support both ongoing and new  activities
            for the full triennium. No funds were included for  the  kidney  disease
            proposal; for the mobile coronary care proposal; or for the basic training
            of Inhalation Therapists.






             Page 3   Acting Director, RMPS
             The consultants also recommend that the Region be authorizedIto use.up
             to 10% of its FY 71 $863,996 level for Developmental Component purposes
             and that the local RIP review process meets the minimum requirements
             for decentralization.





             @Lorraine M. F
             Program Analyst
             Gtants Review Branch




                                                              A Privileged Communication



                                       SITE VISIT REPORT
                        WESTERN PENNSYLVANIA REGIONAL MEDICAL PROGRAM


                                      March 10-11, 1971



          SITE VISITORS

          Leonard Scherlis, M.D., Chairman, Professor of Medicine and Chief,
            Department of Cardiology, University of Maryland Hospital
          Franklin G. Ebaugh, M.D., Consultant, Dean, College of Medicine,
            University Medical Center, University-of Utah

          John A. Mitchell, M.D., Consultant, Deputy Director, California Committee
            on Regional Medical Programs
          Edith V. Olson, R.N., Consultant, Nursing Coordinator, Rochester Regional
            Medical Program
          Frederic Westervelt, M.D., Consultant, Assistant Professor of Internal
            Medicine, University of Virginia Medical School

          REGIONAL MEDICAL PROGRAMS SERVICE STAFF

          Gerald Gardell, Chief, Grants Management Branch
          Rebecca Sadin, Continuing Education Branch
          Loretta Brown, Planning and Evaluation Branch
          James Smith, Regional Development Branch
          Lorraine Kyttle, Grants Review Branch
          Clyde Couchman, Re ional Office Representative
                            9
          Rodney Mercker, Grants Management Branch

          WESTERN PENNSYLVANIA REGIONAL MEDICAL PROGRAM STAF_

          F.S. Cheever, M.D., Coordinator, WP/RMP; Vice-Chancellor, Health Professions,
            University of Pittsburgh
          Robert R. Carpenter, M.D., Director, WP/RMP
          Enid Goldberg, Ph.D., R.N., Assistant Director for Nursing and Allied Health
          H.J. Simmons, III, Assistant Director for Hospital Liaison
          David E. Reed, M.D., Assistant Director, Evaluation and Medical Practice
          George P. Sartiano, M.D., Assistant Director for Oncology
          Ruth N. Mrozek, R.N., Nurse Specialist in Oncolojgy

          REPRESENTATIVES OF WESTERN PENNSYLVANIA REGION

          James A. Rock, M.D., Chairman, WP/RMP Advisory Committee, Department of
            Pathology, Lee Hospital
          Kenneth D. Rogers, M.D., Chairman., Department of Community Medicine,
            University of Pittsburgh




         WESTERN PENNSYLVANIA RMP               -2-                      RM 00041


         Harry K. Wilcox, Vice-Chairman, WP/RMP  Advisory  Committee;  Administrator,
           Westmoreland Hospital
         Jack D. Myers, M.D., University Professor, School  of  Medicine,  University
           of Pittsburgh School of Medicine
         Constance Settlemyer, Assistant Project Director
         Catherine M. Brosky, Project Director
         Lawrence F. Blackburn, M.D., Westmoreland Hospital
         Raul Mercado, Jr., Pl.D., Department of Radiology.,  Presbyt6rian-University
           Hospital
         Donald Cohen, M.D., Pathologist, Sharon General Hospital
         Dane R. Boggs, M.D., Department of Hematology, University of Pittsburgh
           School of Medicine
         Nathaniel Murray, President, Sickle Cell Society
         James A. Stewart, Jr., M.D., Director of Ambulatory Care, Mercy Hospital
           of Pittsburgh
         Donald N. Medearis, Jr., M.D., Dean, School of.Medicine, University of
           Pittsburgh
         Mrsi Hattie Hickman, Staff, Pittsburgh Model Cities Agency
         Thomas W. McCreary, III, Rochester General Hospital
         Lee H. Lacey,- Executive Vice-President, Harmarville Rehabilitation   Center
         Mrs. Maude H. Malick, OTR, Director, Occupational Therapy, Harmarville
           Rehabilitation Center
         Daniel E. Leb, M.D., Director, Renal Therapy Unit, Presbuterian-University
           Hospital
         Edward F. McCrossin, Jr., Secretary, WP/RMP  Advisory  Committee;  Executive
           Director, Hospital Council of Western Pennsylvania
         Marguerite J. Schaefer, Dean, School of Nursing,  University  of  Pittsburgh
         David W. Clare, M.D., Chairman, WP/RMP Cancer Committee
         John G. McCormick, Chairman, WP/RMP Community Involvement Committee;
           Associate Executive Director, Health and Welfare Association of
           Allegheny County
         Dan J. Macer, Chairman, WP/RMF Bylaws Committee;"Assistant Vice-Chancellor,,
           Health Professions, University of Pittsburgh
         Edward H. Noroiah, Chairman, WP/RMP Nominations Committee; Executive
           Director, Presbyterian-University Hospital
         J.E. Ricketts, M.D., Chairman, WP/RMP Stroke Committee; M edical   Director,
           Harmarville Rehabilitation Center
         Waldo L. Treuting, M.D., Chairman, Board of Directors, Western Pennsylvania
           Comprehensive Health Planning Agency; Professor and Head of Department of
           Public Health Practice, Graduate School of Public  Health,  University  of
           Pittsburgh
         Frank M. Mateer, M.D., West Penn Hospital, Pittsburgh, -Pennsylvania





          WESTERN PENNSYLVANI@A RMP            -3-                    RM 00041



          INTRODUCTION

          The site visit was in response to an application from the Western
          Pennsylvania Regional Medical Program proposing a three-year plan of
          action and growth. Under the Anniversary Review and  Award  System,  the
          WP/RMP had no options to submit applications during its  second  operational
          year.  The request submitted for this review cycle reflects the Region's
          decision to submit a triennial application on its anniversary  rather  than
          an application geared only to its plan for the next year.
          In addition to displaying the specific activities to be continued  and  new
          activities to be initiated in the upcoming year, the  application  described
          new thrusts presently in the planning stage which Are  scheduled  for  activa-
          tion in the second and third years of the triennium.

          The purposes of the site visit were to assess the Region's  overall  progress,
          its current quality, its prospects for the next three years, and  to  arrive
          at a funding recommendation based on the intrinsic quality of  the  program.

          ORGANIZATION OF THE REGION

          James A. Rock, M.D., Department of Pathology, Lee  Hospital,  Johnstown,
          Pennsylvania and Chairman of the Regional Advisory Committee,  and  F.S.
          Cheever, M.D., Vice-Chancellor, Health Professions, University of Pitts-
          burgh and Coordinator, Western Penns,rlvania RMP opened the meeting with  a
          short resume of the Organization of the Western Pennsylvania RMP.  WbLeri-the-
          legislation on regional medical programs was passed, Dr.  Cheever  gathered
          approximately 50 medical and hospital leaders in Western  Pennsylvania  who
          decided to develop a planning grant application.  The University Health
          Center of Pittsburgh was agreed on as the grantee. This  is  a  corporation
          originally composed of four and now comprising five large hospitals affiliated
          with the University for teaching, training and  research.  Once  the  planning
          and initial organizational effort was accomplished, the  Region  experienced
          difficulty in getting off the ground until Dr. Carpenter  was  appointed
          Program Director. In response to a request for more detail  on  the  Cheever
          vis a vig Carpenter relationship, Dr. Cheever replied that Dr. Carpenter
          as Program Director "does everything" and that he (Cheever) serves in a
          supplementary role, principally as the link between the RMP and the University.
          Dr. Carpenter volunteered that he values Dr. Cheever's relationship  not  only
          to the Board of Trustees but to other segments of the  community  RMP  serves.
          Dr. Cheever had mentioned certain distrusts in the medical community concerning
          RMP in its formulative stages. Dr. Rock, in responding to a  site  visit  team
          question regarding that point, feels RMP afforded the first real  forum  in'
          which some of these distrusts could be dispelled. In Dr.  Rock's  view,  the
          combination of Dr. Cheever's link with the University and  Dr.  Carpenter's
          method of operating with medical communities in the Region are  very  valuable
          attributes and contribute heavily to the RMP's success.
          Dur-ing this discussion, the team learned of the existence of a "Coordinator's
          Staff Conference." This group, which is not shown in the  Region's  organiz@l-
          tional structure chart in the application, is composed of some  six  or  seven
          members. It meets with Dr. Cheever every fortnight or  when  it  has  business




          WESTERN PENNSYLVANIA RMP               -4-                    RM 00041


          to discuss. 'At this time, its members include Dr. Carpenter, Dr. Rock,
          Dr. Medearis, Mr. Macer, Dr. Cheever, Dr. Rogers, Dr. Leonard  and  Dr.  Johns.
          Dr. Cheever Iescribed it as a mechanism to exchange information  with  no  legal
          responsibilities or accountability. Dr. Rock was asked  if  this  means  the
          WP/RMP operated on two levels. He replied that  Dr.  Cheever  guides  rather
          than pushe s--that the RAC is quite open in its deliberations  with  no  problem
          regarding the Coordinator's Staff Conference--RAC has never  felt  they  were
          constrained by either Dr. Cheever or the grantee--the Board  of  Trustees  had
          never vetoed a RAC action.  The site visit team met privately with Dr. Carpenter
          the next morning to discuss several points one of which was   the   rationaleof
          continuing the organizational structure whereby Dr.  Cheever  is  designated
          Coordinator (with a "Staff Conference" mechanism) and Dr. Carpenter is
          Director of the program. Dr. Carpenter stated  that  the  current  arrangement
          is acceptable to him; that it affords him the opportunity to  relate  to  the
          medical community in Allegheny County in the different manner that is required;
          that he would not want to work in.a regional medical  program  without  strong
          University ties; that to operate differently.in reaching  the  community  would
          possibly be to have the program under CHP; that he believes  we  are  feeling
          the pressures to politicize the program.

          After discussing the role of the University Health Center  of  Pittsburgh  as
          the grantee, the team concluded that many of the  general  responsibilities  and
          specific assurances vested with most grantees seem to have  been  delegated  by
          the Center to the extent that the grantee may be.a paper corporation.

          Dr. Donald N. Medearis, Jr., Dean of the School of Medicine, University
          of Pittsburgh, described the Relationship of the Health Center  and  the  RMP.
          He said the school has the pleasure and the obligation to participate.
          Because he views continuing education as becoming ori-ented  towards  "career
          renewal" he sees the University playing a larger role in that  field  and  that
          Medical School/RMP relationships will increase. The  expansion  of  the  cate-
          gorical emphasis to primary and comprehensive health care  will,  he  feels,
          help this relationship.

          OBJECTIVES AND PRIORITIES

          Dr. Kenneth D. Rogers, Chairman of the Department of Community  Medicini!,  and
          one of the original WP/RMP proponents, spoke about Setting  Objectives  'and
          Priorities. Dr. Rogers said that their firstefforts  were  to  fund  activities
          that they felt were visible, high impact projects.  The  Region  was  struggling
          with its own objectives which had not been defined nationally.  The RAC estab-
          lished a task force (composed of RAC members plus other providers in the
          community) which developed objectives based  on  "best  practices."  Through
          evolution they found that staff, project proposers, and RAC's ideas were
          beginning to jell and that they were more comprehensive than they had
          originally thought. When the objectives were charted, the  grid  began  to  fill
          in and yet it provided for innovation.

          Mr. Harry Wilcox, Vice-Chairman of the RAC  and  Administrator,  Westmoreland
          Hospital, Greensburg, Pennsylvania spoke on Management by Objectives.  He said
          objectives were the result of strategic  planning.  This  includes  regional
          allocation of resources and upward and downward movement of ideas.




          WESTERN PENNSYLVANIA RMP               -5-                 RM 00041


          Dr. Jack D. Myers, Professor, School of Medicine, spoke on
          The Innovator. In addition to the structured system, Dr. Myers  has  championed
          the need for a person with a different idea to have access through the  system.
          He feels seed money should be available for innovative opportunities and  feels
          RMP has displayed good vision in this area.
          Dr. Rock covered the Ordering of Priorities and in his opening  remarks
          alluded to his interest in how RNPS set its priorities with $70  million.  A
          planning conference attended by 250 volunteers attempted to establish  priorities.
          Group dynamics and discussion in the sub areas and Area Advisory Groups with
          input from staff as well as budget restrictions all contributed to  the
          Ordering of priorities. Staff brings these from the LAC to the RAC and  RA,'
          refin.6s.  The present plan was begun as a tentative plan; was found to be
          workable and is now called the current plan; it will be revised  constantly  as
          requirements dictate. National priorities were identified as  one  measure  for
          a revision requirement.
          Dr. Carpenter described the Role of Staff in setting objectives and priorities.
          He placed staff in the role of the change agent, sensitive to  national
          priorities.  He stated that the RAC did not always buy staff's ideas on
          priority ordering, and gave primary care as an example.  Of some 50 sub-
          objectives developed almost two years ago, 15 are implemented, 14 are underway,
          nine have been dropped (unproven health care objectives) nine are  stalled  and
          three.are being developed at this time.
          Sharp questioning followed these presentations concerning what the site
          visitors perceived as an almost exclusively provider-oriented system.  Dr. Rock
          stated he feels RMP/CHP are the two most important agents in  Western  Pennsyl-
          vania for impact on health care delivery. He feels that RMP  should  be
          provider-oriented because it asks providers already working in the  delivery
          system for voluntary efforts to change and improve that system.  He sees the
          provider-oriented base of WP/RMP as a natural division between CHP and  RMP.
          He conceded that CHP in some parts of Western Pennsylvania is  still  formulative,
          thereby giving the consumer no real voice.  Dr. Rock also is a member of the
          CHP Council.  Dr. Rogers stated that the stance WP/RNP took allayed the appre-
          hensidn of the medical community who realized they would not be overwhelmed by
          other forces. He feels that the term "provider-oriented" should  be  more  clearly
          restated as based on need and realities rather than on consumer  demand.  It  was,
          he said, the provider's perception of need that led them to the  "best  practices"
          concept. Dr. Carpenter stated that within their best  practices  concept  built
          on need, the RAC has rejected more proposals than it has approved and that
          the rejections were based on both poor technical quality as well  as.low  priority
          need for the Region.

          EVOLUTION OF PROJECTS AND FEASIBILITY STUDIES
          Dr. Alvin Shapiro described the ongoing Hypertension Management  project  which
          is entering its last year of RMP committed support.  The knowledge gained
          through this effort hopefully will result in future funding through the
          community hospitals and NIH.  Dr. Rock identified Dr. Shapiro as an early
          University self-starter who saw RMP as a valuable community link.  In addition
          to the small RNP investment Dr. Shapiro had garnered a great deal of Universi-ty.
          manpower and money for the project.





           WESTERN PENNSYLVANIA RMP                -6-                   RM 00041


           Dr. Enid Goldberg described the ongoing Coronary Care Nurses project which
           enters its final year of RMP support.  The Region feels it is a highly
           successful program.  Dr. Carpenter stated that in their order of priorities
           partial support from RMP is possible but it will probably fall  below  a  total
           support base.

           Miss Catherine Brosky discussed the ongoing Regional Library System and
           Dr. Carpenter outlined his plans to obtain future partial support for this
           activity through hospitals,(by charge) and the National  Library  of  Medicine.

           Next the team learned about the effect of feasibility studies.

           Mr. Wilcox and Dr. Lawrence Blackburn both of Westmoreland Hospital traced
           the opportunity, through the responsiveness of RMP, to develop a study of
           earlycoronary care in Westmoreland County. The study  was  initiated  July  1969.
           The County was the first Area in the Region with a coronary care  unit  and  the
           topic in the medical community is transportation of  the  coronary  patient.  Two
           proposals emerged --- one was rejected by the RAC and one approved.    @e-latter
           is included in the present application. RMP contributed less  than  50%  of  the
           total cost. The area advisory group zeroed in on a  mobile  coronary  care  unit
           rather than equipping a conventional emergency vehicle to  reduce  variables  and
           increase evaluation benefits.

           Drs. Raul Mercado, George Sartiano and Donald Cohen,  discussed  the  value
           of feasibility studies conducted with partial RMP support in the cancer @rograF-,,-
           area.  They described,the thin distribution of resources outside the Pitrs-
           butgh area and as a result of.the study decided  to  develop  continuing  educa-
           tion programs based in local hospitals. One of the valuable  spin  offs  of  the
           study is.that radiologists are now willing to send their  patients  for  radio-
           therapy consultation to the Center.

           Dr. Dane Boggs, Mr. Nathaniel Murray and Dr. James Stewart  discussed  how  the
           sickle cell project evolvedfrom a feasibility study  started  a  year  ago.
           As part of a survey, it wa4 found that seven out of eleven  people  in  the
           Allegheny County area did not.know what sickle cell disease was. 70%  of  t'.Ie
           Region's Black community lives in Allegheny County.  The  group  has  developed
           a public awareness plan of what can be done for people suffering from the
           disease.  A Sickle Cell Society has been formed and a:screening program is
           on the books.  The group also has worked thru the Allegheny County School
           system with enthusiastic acceptance.  The University of Pittsburgh has launched
           a research program and is merging with other research efforts  in  the  country.
           Realizing that not all of the Black community would receive  hospital  care  in
           areas that are acutely aware of the disease, the society is sponsoring a program
           beamed at the staffs of those hospitals to make them more aware  of  the  disease
           and the trait.  They are also working on the emergency room problem.  Screening
           and genetic counselling are items to be pursued under the operational 'lan.

           Dr. Carpenter summed up this portion by saying that generally, feasibility
           studies fall into two categories:

                  Those that pre-study the plan for a project  and  those  that  build
                  on existing data from the  Hospital  Utilization  Plan  system.  The
                  Western Pennsylvania RMP is a participant in HUP.




           WESTERN PENNSYLVANIA RMP               -7-                 RM 00041


           David Reed, M.D., Assistant Director for Evaluation and Medical Practice,
           WP/RMP, told the team about the Region's Use of Evaluation and Plannia
           Data. The Region participates in the Harvard Information Support  System  which
           uses a broad sociologic program approach.  They believe the inputs from the
           system are helpful but in their view the study needs a stratafied listing
           of persons aware of health care problems.  In addition to Dr. Reed's core
           staff activities, evaluation has built on other small segments and efforts
           not qualifying as feasibility studies or projects. The Region had  developed  a
           standard quarterly reporting format for project'directors supplying data
           sheets and anecdotal information.  The Region is collecting measures of
           behaviorial and attitudinal change and is tackling the total sociological
           measurement which they described as a tough challenge. As an example  of  one
           effort to evaluate a facet of total program impact, the Region is measuring
           the man hours of University personnel spent directly in or with the  community,
           measuring the Region's 01 year against its current 02 year.  The  opportunity
           to review the medical practice records of many of the Region's hospitals  had
           been successfully courted and Drs. Carpenter, Reed and Rogers are engaged  in
           that effort with assistance of medical students.

           WHERE THE REGION IS GOING
           Mr. Edward McCrossi.n, Jr., Director of the Hospital Council of Western
           Pennsylvania and Secretary of the RAC discussed the Effectiveness and  Future
           Role of the Program. Mr. McCrossin is also Chairman of  the  RAC's  Operational
           Grant Review Committee.  He said it was very difficult to interconnect the
           Region.  The terrain has resulted in hospitals built on local bases.  The Region
           has never before been served or surveyed on a regional basis by any act
           planning group.  (Mr. McCrossinis emphasis).  The Region's hospitals are
           terribly obsolete. He thinks RMP has fielded a well balanced program  and  is
           delighted with the uniqueness of the program not being structured on the  basis
           of population or State lines.  Within his experience, he has found no -)ther
           program that could transport planning into action in areas with-essential
           hostilities to any other area or large city the way Western Pennsylvania  RMP
           has.  He would never have believed two years ago that a small community
           hospital would give its records to a planning body for audit of  medica  care
           rendered.  Mr. McCrossin feels strongly that RMP is the first agent in the
           area that has demonstrated the ability to coordinate and that if the CHP  has
           the effect of review and comment authority "they had better have the  expertise
           to do it,"
           Dr. Carpenter then led a discussion of Projects Proposed in the  Current  Plan.
           On the subject of Primary Care he was joined by Marguerite Schaefer, Dean  of
           the School of Nursing, Mrs. Hattie Hickman of Model Cities Agency and Mr.  H.J.
           Simmons, Assistant Director for Hospital Liaison, Western  Pennsylvania  sta  .
           Dr. Carpenter started the'discussion by stating that primary care is  different
           things in different parts of the Region. Some of it takes the form  of  psycho-
           social support. He feels they can go so far in primary care planning  but  do
           not have the resources for the primary care involved.  RMP representatives,
           the Vice-Chancellor and union representatives met recently  to  develop  guide-
           lines for an HMO. The Model Cities representative described the plight  of  the




            WESTERN PENNSYLVANIA                -8-                 RM 00041

            Pittsburgh area.  There seems to controversy over the,number of hospital
            beds needed and over the question of renovating existing antiquated
            facilities versus building.  They hope RMP can help with planning assistance.
            The Region's proposed referral project, still in planning stage, is-endorsed
            and needed.  Dean ';chaefer described the proposed pediatric nurse practitioner
            program and its future contribution to comprehensive primary care.  She said
            it stemmed from an RMP based limited feasibility study the summer before.  It
            began as an experiment with ten trainees.  She already sees things that will
            be changed the next time around.  The next step is the medical nurse practi-
            tioner.  She feels the combination of the     atric and medical nurse i)racti-
            tioner will make a real impact.  She plans to modify.the curriculum of-the
            preprofessional students in nursing so that four years hence graduates will
            be prepared to practice in the specialty practice of ambulatory health.
            care..   She states she will have no trouble filling 100 slots -- the experiment
            was-twice subscribed without recruitment.  The VNA director is retiring and
            they are now recruiting her replacement.  She sees the possibility of a
            combination VNA-PH nurse.. There is no in-house setting where family practie-
            tioner experience can be gained.
            Mr. Thomas W. McCreary of Rochester General Hospital, Beaver County,
            Pennsylvania and Ruth N. Mrozek, R.N., WP/RM@ staff spoke about the Regionis
            developing plans for nursing support of the community hospital cancer care
            team.  Miss Mrozek is a graduate of the Master's degree program for cancer
            nurse specialistaatlu-the Pittsburgh School of Nursing.  The cancer care team
            activity is receiving support from local Cancer Societies and with comple-
            menting RMP funds is scheduled for operation in Mid 1971.  It is estimated
            that 70-80% of the required support should be self-generated after the first.
            year of its operation.
            Mt. Lee Lacey, Executive Vice President of the Harmarville Rehabilitation
            Center, Harmarville, Pennsylvania, and Mrs. Maude Malick, OTR,, also Df the
            Center described the plans for a rehabilitation mobile training and demonstra-
            tion activity for MD's RN,'s, PT's, OT's and supportive personnel.  The vehicle
            is still in the design sfage -- one of its uses is to complement the ILMP
            ongoing nursing homes project.  Four areas with an estimated 3,000 paralysis
            patients are being studied.  There are no rehabilitatio  facilities in the
            areas other than a County Home and a VA hospital.  Local hospitals are
            identifying discharged patients requiring rehabilitation.
            Of the five specified new activities to be implemented in the first year of
            the Region's triennium, only the revised kidney disease project was subjected
            to an in depth review.  Dr. Westervelt met separately with Dr. Leb, the
            proposed acting project director, and Dr. Westervelt's comments have been
            forwarded to the ad hoc technical panel meeting today on kidney disease proposals.
            Dr. Westervelt's conclusions were that the proposal could not be supported in
            its present form but that a little "developmental money" could help this
            potentially capable (if better organized) group get this project going.





          WESTERN PENNSYLVANIA RMP               -9-                 RM 00041


          The Executive Committee jointly discussed the Strategy for  Developmental
          Component which covered the areas of the value of the feasibility activity;
          the review mechanism for a developmental component and the effect of  limited
          funds on propram development. The following is an abbreviation  of  their
          collective statements:

               *  The Executive Committee meets monthly and is composed of all  the
                  Chairmen of the special committees plus the Chairman of the  RAC,
                  a Vice Chairman (Mr. Wilcox), a Secretary (Mr. McCrossin who is  also
                  Chairman of the Operating Grant Review Committee) and Dr.  Cheever.

               *  So much of what has been done in the past was through the Developmental
                  Component concept funded with carryover that if no  developmental
                  funding is permitted, it will have a drastic effect on the program.

               *  They are deeply concerned over how much real autonomy will be permitte

               *  They have a constituency of approximately 460 involved providers  and
                  they feel the full RAC has demonstrated tremendous  commitment.  Even
                  with the Region's terrain which makes travel difficult, a very stringent
                  flattend or be dropped" rule resulted in the loss of only six out of 48
                  members.  Replacements are being considered.

               *  RAC has had to make decisions before, b'ased not only on quality and
                  need, but on funding restraints and they can do it again.

               *  Retrenched funding will require the consideration  of  reordering
                  priorities which will begin with Staff consultation with local
                  advisory groups, a proposal developed by the Executive Committeei
                  and presentation to the full RAC for discussion.

               *  They feel the program as it is presently constituted has a  level
                  below which it cannot operate and significantly retrenched  funding
                  will reqfiire the scrapping of a highly successful concept.

               *  The existing review procedures will apply for developmental component
                  proposals with latitude delegated to the Program Director to  act
                  independently in cases combining a request for less than $10,000  for
                  a duration of less than 12 months. Periodic post reporting  to  the
                  RAC is required.

          Waldo Trueting, M.D., Chairman of the Board of Directors, Western  Pennsyl-
          vania Comprehensive Health Planning Agency and Professor and Head of  the
          Department of Public Health Practice, University of Pittsburgh, was joine
          by Mr. Dan J. Macer, Assistant Vice-Chancellor, Health Professions and
          Chairman of the RMP-CHP Task Force in a discussion of the Relation of RMP
          and CHP. CHP in Western Pennsylvania became operational in  December  1969.
          Dr. Trueting said RMP was instrumental in getting them started. They  had  no
          money while RMP had both dollars and interest. Mr. Macer  was  instrumental
          n interesting representatives from 31 counties in Western  Pennsylvania  an
          i





           WESTERN PENNSYLVANIA PM.
                                                    -lo-                  RM 00041


           Southeast Ohio as  Ueil as  the West Virginia panhandle.  The  final   proposal
           covered 12 counties in-Southwgstern Pennsylvania in forming    six sub-area
           Councils.  of 69 members of the area Council, 37 are consumers.  The B
           agency formed went directly to an operational status.  There i
                                                                            s overlapping
           RNP-CHP membership on the board at the A level.  Mr. Macer is the Chairman.
           Dr. Rock is another overlapping  member.  CHP  in  Western  Pennsylvania  does
           not consider itself a master planning agetrcy--it feels its role is to
           stimulate and coordinate the planning of agencies.  The B agency has no
           regulatory authority.  Other-B.agencies are being planned,    but other th-iifi
           the two that have been fatui6,a, no others exist at  this  time.

           THE CONCLUSIONS OF THE CONSULTANTS
           The visitors,c ame away with concerns in some areas,  but  with  the  unanimous
           impression that they had visited an energetic, effective region.

           The areas of concern are:
           This is a  provider-oriented program that deeply  feels  the  politicizing  of
           health care programs is the business of CHP -- it  sees  this  as  the  natural
           division between the two programs.  It  candidly  attributes  its  progress  to
           its provider base.  Agreement was reached to expand its representative
           structure to include the social groups it serves.
           The visitors believe that many of the general responsibilities and specific
           assurances vested with most grantees have been  delegated  in  this  region  to
           such an extent that the.grantee may  be  a  paper  organization.

           The areas of strength:
           A tremendously energetic Core 'Staff, bound together by unusual espirt
           de corps and competence.
           An involved and knowledgeable Regional  Advisory  Committee  that  listens  to
           and works well with its Local Advisory  Committees.  The  Chairman  is  a  real
           plus.
           The talent of attracting the time and attention  of  U'miversity  faculty  with
           strong action and community-oriented  bents.  These  are  volunteers  and  are
           not on the RMP payroll.
           The knack of identifying local resources and good local leadership.  Western
           Pennsylvania's terrain makes travel difficult, particularly during the winter,
           and even with a very stringent "attend or  be  dropped"  rule,  Local  Advisory
           Committees and Regional Advisory Committee involvement is very good.
           A highly qualified gvoup of nurses, including the Dean of the School of
           Nursing, who are deeply committed to the program.
           The skillful use of feasibility studies and seed money to address new
           priorities.                                                                           ,





            WESTERN PENNSYLVANIA RMP                                        RM   00041


            Generally, the organizational structure is good, with reservations about
            the Coordinator/Director arrangement.

            The ongoing operational projects are making excellent progress, considering
            the fact that the Region is only in its second operational year and two
            activities are in their first year.

            The Region's progress in the area of project and program evaluation is very
            good and its new approaches to total impact measurement are excellent.
            The local review  process  meets  the  requirements  for  decentralization.
            The Region had  demonstrated  the  capability  to  receive  developmental  component
            funds.
            The goals and objectives are clearly  stated  and  well  aligned  to  the  Region's
            operational  approaches.  The  decision-making  bodies  that  developed  them  also
            developed mechanisms for priority re-ordering.  Improvement could be made
            here by interfacing goals  and  objectives  with  total  program  targets--that  is,
            to first state the changes in health care'delivery the program hopes to effect
            in addition to stating the  methodology  the  Region  intends  to  pursue.

            FUNDING RECOMMENDATIONS:

                   Present Level               Requested Levels             Recommended

                     $1,248,391               03 yr. - $1,757,550            $1,450,000
                        226,350 is            04 yr. - $1,970,875            $1,450,000
                    carryover from            05 yr. - $2,233,286            $1,450,000
                    the 01 year)

            In arriving at a recommended  level,  the  consultants  computed  the  full  amount
            for a Developmental Component, funds for  some  expansion  of  Core  staff,  and  a
            revolving account for  operational  activities  in  the  neighborhood  of  $700,000
            which must support both ongoing and new activities for the full triennium.
            Based on Dr. Westervelt's findings  after  consulting  with  the  proposers  of  the
            kidney disease project, no funds were included for that activity.  The proposal
            will be reviewed by an ad hoc panel  April  14-15th  for  submission  to  May  1971
            Council.  Also, in view of Council's statements regarding the funding of
            mobile coronary untts, no funds  were  included  for  the  proposed  Ear  y  oronary
            Care project. Funds were also  deleted  for  that  portion  of  the  Bucktail  Area
            Emphysema and Pulmonary Disease Project which covers the basic training of.
            Inhalation Therapists.
            Following the feedback session, Dr. Rock thanked the visitors for sharing
            their views with the Region and asked that as part of a two way communication,
            the team relay.the following message from the Region:
                  The deeply involved manpower in the Region constitutes a valuable
                  constituency and yet they  are  frustrated  by  changing  leadership
                  at the Federal level and by their inability to understand the
                  rationale of constantly shifting "rules.   to If they are to  be  of
                  real  va.lue, RMPS simply must get away from the "carrot and-stick"
                  basis of operation.





          WESTERN PENNSYLVANIA RMP              -12-                   RM 00041


               During the past year, it has @n  extremely,di-ificalt  to  uccessfull
                                                                        s          y
               relay to their very strong area groups who have deep commitments to the
               program that limited funding simply does not permit them to do many of
               the things they know need to be done.
               Dr. Rock acknowledged this as only his second meeting with Mr. Couchman
               and his first contact with Mr. Smith.  He asked that RMPS representatives
                meet with us when we meet" as the only.real way they will.understand
               the Region.